An outbreak of measles among young adults. Clinical and laboratory features in 461 patients

Clinical features and mechanism of liver injury in patients with mild or moderate coronavirus disease 2019

Background and Aim

We aimed to identify clinical features that suggest that coronavirus disease 2019 (COVID-19) should be a differential diagnosis in patients presenting with a chief complaint of fever and abnormal liver function.

Methods

We retrospectively studied the presence or absence of abnormal liver function in 216 patients diagnosed with mild-moderate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection between February and September 2020.

Results

Abnormal liver function was observed in 51 patients with mild-moderate COVID-19. The median peak aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) levels were 57.5, 75.5, and 332.5 U/L, respectively. The median number of days from symptom onset to peak AST, ALT, and LDH were 8.5, 9, and 8.5, respectively. The median peak LDH/AST ratio was 9.0. Low lymphocyte-to-white blood cell ratio and elevated LDH were found to be independent contributing factors for intensive care unit (ICU) admission on a multivariate analysis.

Conclusions

AST-predominant AST/ALT/LDH elevation peaking 8-9 days after symptom onset and not accompanied by elevated alkaline phosphatase or gamma-glutamyl transferase may be a useful clinical feature for differentiating COVID-19 from other diseases. Since the median LDH/AST ratio was 9.0, it seems that the abnormal liver function caused by SARS-CoV-2 is an indirect damage to liver cells due to elevated cytokine levels caused by liver-infiltrating lymphocytes. SARS-CoV-2 infection should be considered in patients presenting with a chief complaint of fever and liver injury; those with a high lymphocyte-to-white blood cell ratio or and a high LDH/AST ratio may be admitted to the ICU.

Measles-related hospitalizations and associated complications in Jerusalem, 2018-2019

OBJECTIVES

The 2018 measles outbreak in Israel affected >2000 people in Jerusalem. The aim of the study was to describe clinical features and complications of hospitalized measles patients in Jerusalem, as related to age group and risk factors.

METHODS

All individuals hospitalized with measles in the three main hospitals in Jerusalem during March 2018 to February 2019 were included. Demographic, clinical and laboratory data were analysed.

RESULTS

Of 161 hospitalized individuals, 86 (53.4%) were <5 years old, 16 (10%) were ≥5 years but <20 years old, and 59 (36.6%) were ≥20 years old. Most, 114/135 (85%), were unvaccinated. Immunocompromised state was identified in 12/161 (7.5%) patients, 20/161 (12.4%) had other underlying co-morbidities, and four were pregnant. Hypoxaemia on admission was a common finding in all age groups. Hepatitis was more common among adults ≥20 years old (33/59, 59%). Measles-related complications were noted in 95/161 (59%) patients, and included pneumonia/pneumonitis (67/161, 41.6%), which was more common in young (<5 years) children, diarrhoea (18/161, 11.2%), otitis (18/161, 11.2%), and neurological complications (6/161, 3.7%)-the latter occurring more frequently in the 5- to 20-year age group. Two of the 12 immunocompromised patients died of measles-related complications. A high re-admission rate (19/161, 11.8%) within 3 months was documented among hospitalized measles patients.

CONCLUSION

The burden of hospitalization, as well as the high rate of short- and long-term complications observed in hospitalized patients, underscore the importance of maintaining a high measles vaccine coverage, with enhanced targeting of unvaccinated population pockets.

The Reemergence of Measles

Measles, or rubeola, is a highly infectious, acute viral illness of childhood that is considered eliminated in the USA but has reemerged in the past few years. Globally, an estimated 20 million cases of measles continue to occur, and it remains a leading cause of death among young children. It is rare in the USA and other first world countries, but numerous outbreaks have occurred in the USA recently, due to a combination of factors including poor vaccine coverage and importation of cases among travelers returning from endemic areas. The diagnosis of measles is usually made clinically, when an individual presents with a constellation of symptoms including cough, coryza, conjunctivitis, high fever, and an erythematous maculopapular rash in a cephalocaudal distribution. Complications are common and include otitis media, pneumonia, encephalitis, and rarely death. A measles vaccine is available in two doses and provides excellent protection against the disease. Despite this, vaccination coverage, especially among young adults, remains poor. Given its resurgence in the USA and other countries, interventions are urgently needed to address low vaccination rates and vaccine hesitancy. Measles awareness should also be a priority among young clinicians, who may have never seen a case or are not familiar with the disease.

Adult patients hospitalized for measles in France, in the 21st century

BACKGROUND

An epidemic of measles broke out in France in 2008. We designed a retrospective study focusing on adults hospitalized for measles in 2010/2011.

METHODS

A case was any patient aged more than 15 years, hospitalized (September 2010 to September 2011) with a typical rash or a biological diagnosis. Data was collected with standardized questionnaires in participating hospitals.

RESULTS

Four hundred and sixty cases were reported: sex-ratio (M/F) = 0.93, median age 26 years (σ = 8.8). Twenty-nine cases were severe (6.5%), 27 of which hospitalized in an ICU. Three hundred and twelve (68%) cases had elevated serum transaminases (EST), 155 (34%) cases had pneumonia, 34 (7%) cases had elevated serum creatinine (ESC), four (0.9%) cases had elevated serum amylase and lipase (ESAL), and three (0.7%) cases had neurological symptoms. One hundred and four (23%) patients presented simultaneously with EST and pneumonia. One patient presenting with severe pneumonia died (0.2%). One hundred and ten (24%) patients received antibiotics during a median seven days.

CONCLUSION

Measles can present as various syndromes in adults and be responsible for a high burden during outbreaks. The immediate outcome is favorable in most patients. Long-term outcome needs further investigations to identify possible late complications.

Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients

France has recently witnessed a nationwide outbreak of measles. Data on severe forms of measles in adults are lacking. We sought to describe the epidemiologic, clinical, treatment, and prognostic aspects of the disease in adult patients who required admission to an intensive care unit (ICU). We performed a retrospective analysis of a cohort of 36 adults admitted to a total of 64 ICUs throughout France for complications of measles from January 1, 2009, to December 31, 2011. All cases of measles were confirmed by serologic testing and/or reverse transcription polymerase chain reaction.The cohort consisted of 21 male and 15 female patients, with a median age of 29.2 years (25th-75th interquartile range [IQR], 27.2-34.2 yr) and a median Simplified Acute Physiology Score (SAPS II) of 13 (IQR, 9-18). Among the 26 patients whose measles vaccination status was documented, none had received 2 injections. One patient had developed measles during childhood. Underlying comorbid conditions included chronic respiratory disease in 9 patients, immunosuppression in 7 patients, and obesity in 3 patients, while measles affected 5 pregnant women.Respiratory complications induced by measles infection led to ICU admission in 32 cases, and measles-related neurologic complications led to ICU admission in 2 cases. Two patients were admitted due to concurrent respiratory and neurologic complications.Bacterial superinfection of measles-related airway infection was suspected in 28 patients and was documented in 8. Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS). Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases. Five patients died, all of whom were severely immunocompromised.On follow-up, 1 patient had severe chronic respiratory failure related to lung fibrosis, and 2 patients had mild lower limb paraparesis along with bladder dysfunction, both of which were ascribable to measles-induced encephalitis and myelitis. Among the 5 pregnant patients, the course of measles infection was uneventful, albeit 1 patient underwent emergent cesarean delivery because of fetal growth restriction.Measles is a disease with protean and potentially deceptive clinical manifestations, especially in the immunocompromised patient. Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality. In contrast with the usually benign course of the disease in immunocompetent patients, measles occurring in immunocompromised patients gives rise to lethal complications including ARDS, with or without bacterial superinfection. Other patients potentially at high risk for severe measles are young adults and pregnant women. Measles pneumonitis may predispose to air leak disease in patients using mechanical ventilation. To date, vaccination remains the most potent tool to control measles infection.

Clinical features of measles according to age in a measles epidemic

The purpose of this study was to retrospectively investigate the relationship between age and clinical manifestations and laboratory findings in patients with measles. The study included 216 patients admitted to a hospital in Daejeon, 1 of the largest cities in South Korea, during the 2000-2001 measles outbreak: very young children (<2 y old; 159 patients), school age children (9-11 y old; 34 patients), and young adults (>16 y old; 23 patients). Few of the very young children (9%), but most of the older children (86%) had a history of a prior measles-mumps-rubella vaccination. There were no statistical differences between the 3 groups in terms of the total duration of fever, length of hospitalization, occurrence of complications (defined as hospitalization for more than 7 d) or anti-measles IgM positivity. A reduction in the number of white blood cells and lymphocytes was observed in all age groups. The levels of C-reactive protein were not different between very young children and older children, but hepatic involvement was more prevalent in young adults. In conclusion, the clinical course including the complications experienced was similar in all the measles patients regardless of age.

Morbilliviruses and human disease

Morbilliviruses are a group of viruses that belong to the family Paramyxoviridae. The most instantly recognizable member is measles virus (MV) and individuals acutely infected with the virus exhibit a wide range of clinical symptoms ranging from a characteristic mild self-limiting infection to death. Canine distemper virus (CDV) and rinderpest virus (RPV) cause a similar but distinctive pathology in dogs and cattle, respectively, and these, alongside experimental MV infection of primates, have been useful models for MV pathogenesis. Traditionally, viruses were identified because a distinctive disease was observed in man or animals; an infectious agent was subsequently isolated, cultured, and this could be used to recapitulate the disease in an experimentally infected host. Thus, satisfying Koch's postulates has been the norm. More recently, particularly due to the advent of exceedingly sensitive molecular biological assays, many researchers have looked for infectious agents in disease conditions for which a viral aetiology has not been previously established. For these cases, the modified Koch's postulates of Bradford Hill have been developed as criteria to link a virus to a specific disease. Only in a few cases have these conditions been fulfilled. Therefore, many viruses have over the years been definitely and tentatively linked to human diseases and in this respect the morbilliviruses are no different. In this review, human diseases associated with morbillivirus infection have been grouped into three broad categories: (1) those which are definitely caused by the infection; (2) those which may be exacerbated or facilitated by an infection; and (3) those which currently have limited, weak, unsubstantiated or no credible scientific evidence to support any link to a morbillivirus. Thus, an attempt has been made to clarify the published data and separate human diseases actually linked to morbilliviruses from those that are merely anecdotally associated.

The clinical significance of measles: a review

Forty years after effective vaccines were licensed, measles continues to cause death and severe disease in children worldwide. Complications from measles can occur in almost every organ system. Pneumonia, croup, and encephalitis are common causes of death; encephalitis is the most common cause of long-term sequelae. Measles remains a common cause of blindness in developing countries. Complication rates are higher in those <5 and >20 years old, although croup and otitis media are more common in those <2 years old and encephalitis in older children and adults. Complication rates are increased by immune deficiency disorders, malnutrition, vitamin A deficiency, intense exposures to measles, and lack of previous measles vaccination. Case-fatality rates have decreased with improvements in socioeconomic status in many countries but remain high in developing countries.

The high morbidity associated with a measles outbreak in a west Australian town

OBJECTIVE

To determine the effectiveness of the measles vaccine and to record the morbidity during a measles outbreak.

METHODOLOGY

A retrospective cohort study was carried out. It was a community-based study in Bunbury, Western Australia, between February and May 1994, of 53 cases of measles and their household contacts.

RESULTS

Of the 53 cases of measles, 24 were from one high school. Only two cases occurred in the high school class that had received the National Health and Medical Research Council of Australia recommended measles, mumps and rubella (MMR) booster 12 months earlier. Neither had been vaccinated. Vaccine effectiveness was 91% (95% confidence interval 67-97%). Ten cases had complications of measles and a further five were admitted to hospital. Doctors prescribed antibiotics to 29 cases and metoclopramide to five cases. One month elapsed between the day the index case became ill and the first notification to the community health centre.

CONCLUSIONS

The low herd immunity that led to this high school outbreak can be attributed to low vaccine coverage. There was a significant morbidity associated with this outbreak that may have been averted if earlier notification had occurred. The MMR booster dose should be offered to all 10-16 year olds to prevent high school outbreaks.

Measles pneumonitis

STUDY OBJECTIVE

To investigate the finding of increased alveolar-arterial (A-a) gradient in adult patients with measles who have normal results on both pulmonary auscultation and chest radiography.

DESIGN

Retrospective, descriptive case series.

SETTING

An urban county teaching hospital in southern California.

PARTICIPANTS

Consecutive adult patients with the clinical diagnosis of measles seen in the emergency department.

METHODS

Patients were considered to have pneumonitis if they had any of the following: ED diagnosis of pneumonia; an A-a gradient of more than 30 mm Hg; one or more infiltrates on chest radiograph.

RESULTS

Seventy-five patients, including 44 men and 31 women (median age, 25 years; 25% to 75% interquartile range [IQR], 20 to 28 years) were seen during the 36-month study period. Forty-three patients (57%; 95% confidence interval [CI], 45% to 69%) had pneumonitis, with a median A-a gradient of 42 mm Hg (IQR, 34 to 48 mm Hg). Twenty-seven of the 43 patients with pneumonitis (63%; CI, 48% to 77%) had both normal pulmonary auscultation findings and normal chest radiographs; this represented 36% of the study population (CI, 25% to 50%). Thirty-eight of the 43 patients with pneumonitis were admitted; one patient was later intubated after respiratory failure developed. Two of the 5 patients with pneumonitis who were sent home were admitted the following day for worsening symptoms. All 75 patients eventually did well.

CONCLUSION

A significant percentage of adult patients with measles presenting to an ED with both normal pulmonary auscultation and normal chest radiographs have increased A-a gradients. These patients warrant close follow-up and perhaps hospital admission.

Chronology of a hospital-wide measles outbreak: lessons learned and shared from an extraordinary week in late March 1989

In March 1989, Mount Sinai Hospital, a community hospital in Hartford, Connecticut, faced a potential hospital-wide outbreak of measles when eight cases of measles occurred among medical personnel during several days. This article describes the chronology of events, from the initial discovery of the outbreak to the evolution of the hospital-wide containment program designed to protect patients and staff members. Measles IgG immune status was determined for 1249 employees during a 9-day period. Measles vaccine and immune serum globulin were administered to patients and employees. We offer advice from our experience for infection control practitioners who may face outbreak situations in their institutions.

Hypoxemic respiratory failure complicating nosocomial measles in a healthy host

Since 1983 there has been a steady increase in the number of cases of measles reported to the Centers for Disease Control (CDC), and recent large-scale outbreaks have heightened public awareness. Although mortality from measles is considered rare, systemic complications occur frequently. This case highlights the significant morbidity and potential mortality of measles infection in a normal adult host who did not meet CDC guidelines for measles vaccination.

Eye pathology associated with measles encephalitis in hamsters

Measles encephalitis was produced in 41 hamsters by intracerebral injection of the hamster-neuroadapted Mantooth HBS viral strain. Group I (n = 10) included 2-day old (newborn) hamsters, each inoculated with 0.02 ml of 1:20 diluted virus. This group was sacrificed 4 days postinoculation (DPI). Group II (n = 31) included 25-day old hamsters, each inoculated with 0.03 ml of 1:10 diluted virus. This group was sacrificed 6, 13, 17, and 31 DPI. Clinical and histological evidence of measles encephalitis was present in all infected hamsters. Retinal lesions varied with the age of the animals at the time of inoculation. Retinal folds were observed in the 2-day old group and represented one form of retinal dysplasia. In the 25-day old group, however, earliest retinal involvement was in the form of hemorrhages, followed by focal retinitis in animals sacrificed 6-17 DPI. Measles keratitis was noted only in animals sacrificed 6 DPI. In 25-day old hamsters, measles keratitis and retinal hemorrhages represented the acute manifestations, whereas retinitis occurred later. However, ocular involvement did not correlate with the degree of severity of measles encephalitis.

"Just one shot" is not enough--measles control and eradication

The epidemiology of measles in Australia has changed in the last decade due to control of the disease by increased immunization rates. Elimination of endemic measles is possible, but has still to be attempted. A partially immunized population results in disease in an older population, with the possibility of contracting measles in the childbearing years. For elimination of measles to occur, a second dose of measles-mumps-rubella vaccine should be introduced. Changes in the immunization protocol would need to be monitored with reliable population-based data on seroconversion rates and disease incidence. Reliable documentation of immunization is a prerequisite for any legislative initiative in the field of immunization. In order to maximize the impact of immunization programmes, the social and cultural contexts within which immunization occurs should receive greater consideration.

Hepatitis and jaundice associated with measles in young adults. An analysis of 65 cases

We analyzed the clinical course of 65 adult patients hospitalized because of measles during the years 1975 and 1981-1982. Liver involvement was found in 80% (52/65) of the patients, five patients had clinical jaundice. The disturbances of liver function tests reached their peak values between days 5 and 10 of the disease. In this study of measles in adulthood we have three observations of unusual interest: (1) hepatitis occurs commonly in the more severely ill patients and it may manifest clinically as jaundice; (2) long-term follow-up (up to seven years) shows a clear tendency to complete resolution of the liver damage; (3) there is a clear correlation between the severity of hepatic involvement and the occurrence of secondary bacterial infections.