Measles-induced encephalitis

Extracellular vesicles in the pathogenesis of neurotropic viruses

Neurotropic viruses, characterized by their capacity to invade the central nervous system, present a considerable challenge to public health and are responsible for a diverse range of neurological disorders. This group includes a diverse array of viruses, such as herpes simplex virus, varicella zoster virus, poliovirus, enterovirus and Japanese encephalitis virus, among others. Some of these viruses exhibit high neuroinvasiveness and neurovirulence, while others demonstrate weaker neuroinvasive and neurovirulent properties. The clinical manifestations of infections caused by neurotropic viruses can vary significantly, ranging from mild symptoms to severe life-threatening conditions. Extracellular vesicles (EVs) have garnered considerable attention due to their pivotal role in intracellular communication, which modulates the biological activity of target cells via the transport of biomolecules in both health and disease. Investigating EVs in the context of virus infection is crucial for elucidating their potential role contribution to viral pathogenesis. This is because EVs derived from virus-infected cells frequently transfer viral components to uninfected cells. Importantly, EVs released by virus-infected cells have the capacity to traverse the blood-brain barrier (BBB), thereby impacting neuronal activity and inducing neuroinflammation. In this review, we explore the roles of EVs during neurotropic virus infections in either enhancing or inhibiting viral pathogenesis. We will delve into our current comprehension of the molecular mechanisms that underpin these roles, the potential implications for the infected host, and the prospective diagnostic applications that could arise from this understanding.

Clinical features, pathogenesis, pathology, neuroimaging, clinical course and outcome of measles inclusion-body encephalitis: a systematic review of published case reports and case series

Measles inclusion-body encephalitis (MIBE) is rare, with insights largely from case studies. We systematically analyzed subacute Sclerosing Panencephalitis (SSPE) cases in immunocompromised patients, identifying distinctive clinical and neuroimaging features. These findings could facilitate MIBE diagnosis without the need for brain biopsies. Our systematic review on MIBE and HIV-related SSPE adhered to PRISMA guidelines and was registered with PROSPERO. We searched multiple databases and followed a detailed inclusion process with independent reviews and quality assessment. Data on patient demographics, clinical features, and outcomes were compiled. A review of 39 studies on 49 MIBE patients and 8 reports on HIV-positive SSPE patients was conducted. Acute lymphoblastic leukemia, HIV, organ transplants, and malignancies were common precursors to MIBE. Perinatal HIV was prevalent among SSPE cases. Seizures were the primary symptom in MIBE, often drug-resistant and progressing to status epilepticus or epilepsia partialis continua, whereas periodic myoclonus was universal in SSPE. Neuroimaging showed distinct patterns for each group, and histopathology confirmed measles virus presence in 39% of MIBE cases. MIBE patients typically progressed to coma and death. In conclusion, MIBE and SSPE in HIV-infected patients present with distinct clinical pictures but identical brain pathological abnormalities.

Vaccine Associated Measles Complicated by Suspected Measles Inclusion Body Encephalitis in a Pediatric Leukemia Patient and Stem Cell Transplant Recipient: A Focus on Clinical Evolution and Management

BACKGROUND

Immunocompromised individuals are at increased risk for severe disease and complications from viral infections, highlighting the importance of vaccination. However, in extremely rare situations, vaccine associated viral infections can be associated with disseminated disease and complications in immunocompromised hosts.

CASE

Herein, we present a case of a 1-year-old child diagnosed with acute myeloid leukemia less than 2 weeks after receiving live viral vaccines who developed acute vaccine-strain measles virus disease, later complicated by central nervous system involvement following hematopoietic stem cell transplantation. A brain biopsy specimen was positive for vaccine-strain measles virus detected by reverse transcriptase polymerase chain reaction.

MANAGEMENT AND OUTCOME

She was treated with intravenous ribavirin, inosine pranobex, intrathecal interferon-alpha and donor lymphocyte infusion following measles-mumps-rubella vaccine boost. Despite these measures, the patient suffered neurologic decline and dysautonomia, expiring after compassionate extubation. Management and ideal risk mitigation strategies are discussed within the context of existing literature for this rare complication.

Rubella virus chronic inflammatory disease and other unusual viral phenotypes in inborn errors of immunity

Infectious susceptibility is a component of many inborn errors of immunity. Nevertheless, antibiotic use is often used as a surrogate in history taking for infectious susceptibility, thereby disadvantaging patients who present with viral infections as their phenotype. Further complicating clinical evaluations are unusual manifestations of viral infections which may be less familiar that the typical respiratory viral infections. This review covers several unusual viral phenotypes arising in patients with inborn errors of immunity and other settings of immune compromise. In some cases, chronic infections lead to oncogenesis or tumor-like growths and the conditions and mechanisms of viral-induced oncogenesis will be described. This review covers enterovirus, rubella, measles, papillomavirus, and parvovirus B19. It does not cover EBV and hemophagocytic lymphohistiocytosis nor lymphomagenesis related to EBV. EBV susceptibility has been recently reviewed. Our goal is to increase awareness of the unusual manifestations of viral infections in patients with IEI and to describe treatment modalities utilized in this setting. Coincidentally, each of the discussed viral infections can have a cutaneous component and figures will serve as a reminder of the physical features of these viruses. Given the high morbidity and mortality, early recognition can only improve outcomes.

A Measles Outbreak in Riyadh in 2023: Clinical and Epidemiological Characteristics

Background Measles is a highly contagious viral disease that has recently made headlines due to outbreaks in several parts of the world. The disease can cause serious health complications, especially in young children, which has led to concerns about vaccination rates and public health policies. This study aims to investigate and describe the epidemiology, clinical characteristics, and outcomes of measles infection among children in Riyadh. Methodology We conducted a descriptive cross-sectional study among all pediatric patients with confirmed measles infection at a tertiary hospital from January 15, 2023, to March 15, 2023. We collected data including demographic characteristics, clinical presentations, and clinical outcomes. Results A total of 63 confirmed measles cases were reported. Most patients were under four years of age (82.7%), and 85.7% were unvaccinated. Adenovirus was the most common viral coinfection (12.7%). The most common complication was pneumonia (58.7%). Chest X-ray findings reported a localized right parenchymal infiltrate in 19% of patients and a patchy bilateral infiltrate in 15.9% of patients. In addition, 88.9% required hospital admission secondary to dehydration (47.6%) and hypoxia (41.3%). Among admitted patients, 17.5% were admitted to the pediatric intensive care unit (PICU), 9.5% were admitted due to respiratory failure, and 6.3% due to septic shock. Children under one year of age had a higher risk for PICU admission (p < 0.05). The mortality rate was 1.6%. Conclusions Measles is a serious disease that causes significant health effects and incurs high financial costs for public health systems. Vaccination remains the most effective way to prevent measles outbreaks and reduce their impact on individuals and communities.

Associations between early infections and childhood cognition in the Newcastle Thousand Families Study birth cohort

Childhood infections have been shown to stunt growth, contribute to malnutrition and reduce cognition in early adulthood. This study aimed to assess relationships between early life infections and childhood cognition at age 11 years in the Newcastle Thousand Families Study (NTFS). The analysis included 741 members from the NTFS who had complete data for infections between birth and 5 years, and the 11-plus examinations. School records from the 11-plus examinations showed cognitive (IQ), English (EQ) and arithmetic (AQ) abilities. Housing conditions, overcrowding, birth order and social class were recorded at birth. Helicobacter pylori seropositivity was measured at age 49-51 years. Multivariable linear regression was used to examine relationships between infections and cognition. The total number of infections in the first 5 years of life was not significantly associated with IQ, EQ or AQ, nor were there significant relationships between cognitive outcomes and most infections. Tonsillitis did display a positive, significant association with IQ after adjustment for confounders (b = 6.43, 95% CI 0.92, 11.94, p = 0.022). Lower respiratory tract infections (LRTIs) showed significant negative relationships with all cognitive outcomes. H. pylori seropositivity at age 50 exhibited negative, significant relationships with EQ (p = 0.014) and AQ (p = 0.024) after adjustment for confounders. Although no significant relationship between overall infections and cognition were found, there were indications that LRTIs and gastrointestinal system infections may limit cognitive development. Given these infections remain prevalent, further research regarding severity and recurrence of infections and how they affect childhood cognition is needed.

Subacute Sclerosing Panencephalitis in a 63-Year-Old Woman Presenting as Generalized Choreoathetosis

The persistence of measles virus infection in childhood and early adolescence can rarely lead to a fatal progressive neurodegenerative disorder known as subacute sclerosing panencephalitis (SSPE), characterized by behavioral disturbances and intellectual disability followed by myoclonic jerks and occasional negative myoclonus. Movement disorders are rarely presenting manifestations in SSPE. We herein report a 63-year-old woman with generalized choreoathetosis as the presenting manifestation of stage-I SSPE. Our case was atypical for the patient's age and clinical presentation with generalized choreoathetosis and bilateral putaminal and caudate nucleus signal hyperintensity. Though highly uncommon, neurologists should keep SSPE as a differential diagnosis among patients with movement disorders. Measles-endemic countries should be more vigilant to the atypical and rare presentations of SSPE, such as generalized choreoathetosis.

Measles Virus and the Central Nervous System: An Update

MEASLES VIRUS AND ASSOCIATED CENTRAL NERVOUS SYSTEM

Sequelae Renee Buchanan, Daniel J. Bonthius Seminars in Pediatric Neurology Volume 19, Issue 3, September 2012, Pages 107-114 Worldwide, measles remains one of the most deadly vaccine-preventable diseases. In the United States, enrollment in the public schools requires that each child receives 2 doses of measles-containing vaccine before entry, essentially eliminating this once endemic disease. Recent outbreaks of measles in the United States have been associated with importation of measles virus from other countries and subsequent transmission to intentionally undervaccinated children. The central nervous system complications of measles can occur within days or years of acute infection and are often severe. These include primary measles encephalitis, acute postinfectious measles encephalomyelitis, measles inclusion body encephalitis, and subacute sclerosing panencephalitis. These measles associated central nervous system diseases differ in their pathogenesis and pathologic effects. However, all involve complex brain-virus-immune system interactions, and all can lead to severe and permanent brain injury. Despite better understanding of the clinical presentations and pathogenesis of these illnesses, effective treatments remain elusive.

The multitaskers of the brain: Glial responses to viral infections and associated post-infectious neurologic sequelae

Many viral infections cause acute and chronic neurologic diseases which can lead to degeneration of cortical functions. While neurotropic viruses that gain access to the central nervous system (CNS) may induce brain injury directly via infection of neurons or their supporting cells, they also alter brain function via indirect neuroimmune mechanisms that may disrupt the blood-brain barrier (BBB), eliminate synapses, and generate neurotoxic astrocytes and microglia that prevent recovery of neuronal circuits. Non-neuroinvasive, neurovirulent viruses may also trigger aberrant responses in glial cells, including those that interfere with motor and sensory behaviors, encoding of memories and executive function. Increasing evidence from human and animal studies indicate that neuroprotective antiviral responses that amplify levels of innate immune molecules dysregulate normal neuroimmune processes, even in the absence of neuroinvasion, which may persist after virus is cleared. In this review, we discuss how select emerging and re-emerging RNA viruses induce neuroimmunologic responses that lead to dysfunction of higher order processes including visuospatial recognition, learning and memory, and motor control. Identifying therapeutic targets that return the neuroimmune system to homeostasis is critical for preventing virus-induced neurodegenerative disorders.

The Reemergence of Measles

OBJECTIVES

Present-day pathologists may be unfamiliar with the histopathologic features of measles, which is a reemerging disease. Awareness of these features may enable early diagnosis of measles in unsuspected cases, including those with an atypical presentation. Using archived tissue samples from historic patients, a unique source of histopathologic information about measles and other reemerging infectious diseases, we performed a comprehensive analysis of the histopathologic features of measles seen in commonly infected tissues during prodrome, active, and late phases of the disease.

METHODS

Subspecialty pathologists analyzed H&E-stained slides of specimens from 89 patients accessioned from 1919 to 1998 and correlated the histopathologic findings with clinical data.

RESULTS

Measles caused acute and chronic histopathologic changes, especially in the respiratory, lymphoid (including appendix and tonsils), and central nervous systems. Bacterial infections in lung and other organs contributed significantly to adverse outcomes, especially in immunocompromised patients.

CONCLUSIONS

Certain histopathologic features, especially Warthin-Finkeldey cells and multinucleated giant cells without inclusions, allow pathologists to diagnose or suggest the diagnosis of measles in unsuspected cases.

Measles Virus-Induced Host Immunity and Mechanisms of Viral Evasion

The immune system deploys a complex network of cells and signaling pathways to protect host integrity against exogenous threats, including measles virus (MeV). However, throughout its evolutionary path, MeV developed various mechanisms to disrupt and evade immune responses. Despite an available vaccine, MeV remains an important re-emerging pathogen with a continuous increase in prevalence worldwide during the last decade. Considerable knowledge has been accumulated regarding MeV interactions with the innate immune system through two antagonistic aspects: recognition of the virus by cellular sensors and viral ability to inhibit the induction of the interferon cascade. Indeed, while the host could use several innate adaptors to sense MeV infection, the virus is adapted to unsettle defenses by obstructing host cell signaling pathways. Recent works have highlighted a novel aspect of innate immune response directed against MeV unexpectedly involving DNA-related sensing through activation of the cGAS/STING axis, even in the absence of any viral DNA intermediate. In addition, while MeV infection most often causes a mild disease and triggers a lifelong immunity, its tropism for invariant T-cells and memory T and B-cells provokes the elimination of one primary shield and the pre-existing immunity against previously encountered pathogens, known as "immune amnesia".

Measles Induced Encephalitis: Recent Interventions to Overcome the Obstacles Encountered in the Management Amidst the COVID-19 Pandemic

Encephalitis, a well-known complication of measles, is inflammation of the brain parenchyma which is mostly due to the viral invasion of neurons. It presents with a variety of symptoms ranging from mild to severe depending on the extent of the damaged neurons. The diagnosis is based on clinical symptoms such as fever, headache, altered level of consciousness, focal neurological deficits, etc. A detailed history and physical examination facilitate the diagnosis. Investigations include blood tests for measles-specific antibodies, CT, MRI, and analysis of the CSF. The management of measles-induced encephalitis mainly revolves around prevention against contracting the disease and providing supportive care if acquired. The administration of the measles vaccine is the major means of preventing this disease in childhood. Two doses are required to achieve sufficient immunity against measles, the first at the age of 12-15 months and the second at 4-6 years of age. Supportive care includes administering acetaminophen for fever, oral rehydrating salt (ORS) for diarrhea and vomiting, antibiotics for otitis media and pneumonia, and using anti-epileptics such as sodium valproate for seizures. Vitamin A can be given to prevent severe effects in children. The specific treatment would depend on the type of encephalitis the patient has developed.

Measles-Associated CNS Complications: A Review

Measles virus infection is a common infectious disease of childhood, incidence of which is still high in developing countries. Other than the morbidity associated with the acute systemic infection, the measles virus can cause serious fatal neural complications. It can either enter the brain leading to acute encephalitis like primary measles encephalitis and acute post infectious measles encephalomyelitis or it may persist in brain cells (as mutated virus) leading to long-term neurodegenerative diseases like measles inclusion body encephalitis and subacute sclerosing pan encephalitis. The patho-clinical features, treatment, and the outcomes of these complications are different and should be identified in time for early diagnosis and management.

Subacute measles encephalitis in a case of late presenting congenital HIV with epilepsia partialis continua as the first manifestation: A case report

We report a case of a 14-year-old non-immunised girl with a prior history of measles infection presenting with afebrile seizures progressing to epilepsia partialis continua (EPC), quadriparesis and headache. Further evaluation revealed Human immunodeficiency virus (HIV) seropositivity with elevated anti-measles antibody titres in Cerebrospinal fluid (CSF). Electroencephalography showed focal epileptiform activity and Magnetic resonance imaging (MRI) of the brain revealed bilateral, asymmetrical long repetition time MRI (TR) hyperintensities involving juxtacortical white matter in both parietal lobes, left temporal and also in the left basal ganglia without any contrast enhancement or Diffusion weighted imaging (DWI) restriction. We describe the intriguing association of EPC with subacute measles encephalitis/measles inclusion body encephalitis (SME/MIBE) in the backdrop of immunocompromised state (HIV seropositivity), thought to have been acquired by vertical transmission. Also, prolonged asymptomatic HIV infection, first unmasked by measles infection, followed by rapidly deteriorating neurological illness makes this index case worthy to be reported.

An overview of viral infections of the nervous system in the immunosuppressed

Several viruses have the capacity to cause serious infections of the nervous system in patients who are immunosuppressed. Individuals may be immunosuppressed because of primary inherited immunodeficiency, secondary immunodeficiency due to particular diseases such as malignancy, administration of immunosuppressant drugs or organ or bone marrow transplantation. The viruses capable of such opportunistic infection of the nervous system include herpes simplex virus (HSV), Varicella-Zoster virus (VZV), Cytomegalovirus (CMV), Epstein -Barr virus (EBV), Human Herpes virus type 6 (HHV-6), JC virus (JCV), enterovirus, measles virus and Covid-19. In most cases it seems likely that immunological defence mechanisms in the immunosuppressed are deficient which creates a suitable environment for certain viruses to become opportunistic in the nervous and other systems. Further research is required both to understand these opportunistic mechanisms in more detail and also to determine how many virus infections are modified by specific inborn errors of immunological responses.

The neurological sequelae of pandemics and epidemics

Neurological manifestations in pandemics frequently cause short and long-term consequences which are frequently overlooked. Despite advances in the treatment of infectious diseases, nervous system involvement remains a challenge, with limited treatments often available. The under-recognition of neurological manifestations may lead to an increase in the burden of acute disease as well as secondary complications with long-term consequences. Nervous system infection or dysfunction during pandemics is common and its enduring consequences, especially among vulnerable populations, are frequently forgotten. An improved understanding the possible mechanisms of neurological damage during epidemics, and increased recognition of the possible manifestations is fundamental to bring insights when dealing with future outbreaks. To reverse this gap in knowledge, we reviewed all the pandemics, large and important epidemics of human history in which neurological manifestations are evident, and described the possible physiological processes that leads to the adverse sequelae caused or triggered by those pathogens.

Measles Sclerosing Subacute PanEncephalitis (SSPE), an intriguing and ever-present disease: Data, assumptions and new perspectives

BACKGROUND

Subacute sclerosing panencephalitis (SSPE) is a rare, non-treatable and fatal neurological complication of measles, still present due to the return of the epidemic linked to the loosening of vaccination policies. Its mechanism remains unexplained.

OBJECTIVE

The main objective was to investigate explanatory variables relating to the risk of developing SSPE and its pathophysiology.

METHODS

Literature analysis was focused on different varieties of SSPE: perinatal forms, short-incubation forms similar to acute measles inclusion body encephalitis (MIBE), rapidly evolving forms, forms occurring in the immunosuppressed, adult forms, and family forms. In addition, several studies on the parameters of innate immunity and interferon responses of patients were analyzed.

RESULTS

Two main data were highlighted: a relationship between the so-called fulminant forms and the prescription of corticosteroids was established. In familial SSPE, two groups were individualized according to the duration of the latency period, prompting an analysis of patient exomes.

CONCLUSION

Treatment with corticosteroids should be banned. Knowledge of the genes involved and epigenetics should be useful for understanding the pathophysiology of SSPE and other late-onset neurological infections with RNA viruses.

Fatal Measles Inclusion-Body Encephalitis in Adult with Untreated AIDS, France

We report a fatal case of measles inclusion-body encephalitis occurring in a woman from Romania with AIDS. After an extensive but unsuccessful diagnostic evaluation, a pan-pathogen shotgun metagenomic approach revealed a measles virus infection. We identified no mutations previously associated with neurovirulence.

Electroencephalography Patterns of Subacute Sclerosing Panencephalitis

Introduction and background: This article explores the electroencephalography (EEG) pattern in patients of suspected subacute sclerosing panencephalitis (SSPE) visiting Lady Reading Hospital, Peshawar. Pakistan has a huge deficit of research culture, and limited studies are done on this topic. This study concluded that a typical pattern is the most common EEG pattern, although atypical and normal EEG patterns were also observed. It is worth inclusion into the existing literature and may be used for future literature review of similar studies done elsewhere in Pakistan to give a wider perspective comprised of a larger sample size - integrating all studies.

Objective: To determine the frequency of different patterns of EEG (typical, atypical, and normal) in SSPE patients.

Methodology: Seventy-seven patients of both male and female genders between ages one to 20 years, who were diagnosed with SSPE, were included in the study. Dyken’s criteria were used to diagnose the patients. A prior history of previous measles infection with signs and symptoms suggestive of SSPE and positive anti-measles IgG antibodies in the cerebrospinal fluid (CSF) was found in all the patients included in the study. Besides this, typical EEG patterns and raised CSF globulin levels were also used for confirmation of the diagnosis. All the patients fulfilling the above criteria and presenting to the neurology department of Lady Reading Hospital, Peshawar, from February 1, 2019, to November 30, 2019, were included in the study. All the patients underwent the EEG monitoring in the same EEG laboratory and were reported by the same consultant with careful exclusion of any artifacts during the study.

Result: There were 59 (76.62%) males and 18 (23.37%) females. The mean age was 15 ± 8.6 years, and the mean duration of symptoms was 4.79 ± 1.68 months. EEG was normal in 14 (18.18%) patients, while 63 (81.81%) patients had an abnormal EEG pattern, with a majority of 53 (84.12%) patients showing periodic delta wave complexes. Only 10 (15.87%) patients showed atypical patterns.

Conclusion: Almost all the patients of SSPE showed periodic high-amplitude delta waves complexes, which usually occurs in patients with a disease duration of more than four months. However, further studies with a large sample size are needed for the confirmation of this observation.

Severe Measles Encephalitis and Acute Disseminated Encephalomyelitis in an Immunocompetent Japanese Young Male

Measles encephalitis rarely affects young adults and has no established treatment strategy. This brief report described the rare case of an immunocompetent 30-year-old man with severe measles pneumonia and encephalitis, following the autoimmune disease acute disseminated encephalomyelitis, during a large measles outbreak in 2018 in Japan. With multidisciplinary treatments, including corticosteroids, intravenous immunoglobulins, vitamin A, and therapeutic plasma exchange, the patient was successfully treated. This case provides a new strategy for treating measles encephalitis and its complications during measles outbreak.

Severe acute disseminated encephalomyelitis complicating measles infection

A 36-year-old man presented with an acute progressive encephalopathy, followed by tetraparesis and was diagnosed with acute disseminated encephalomyelitis (ADEM) complicating infection with measles virus. Despite demonstrating a typical rash and other early symptoms of measles infection, there was uncertainty around the initial diagnosis. Cerebrospinal fluid analysis and MRI of the brain and spinal cord were consistent with severe ADEM. He required treatment on intensive care but responded favourably to immunosuppressive therapy.This case highlights the importance of recognising acute measles infection, familiarity with the neurological complications and the potential for good outcome. Healthcare professionals must continue to play an active role in educating the public on the importance of maintaining herd immunity through universal immunisation.

Difficulties in diagnosing of measles inclusion body encephalitis in a child with acute lymphoblastic leukemia

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Report of measles inclusion body encephalitis in child with leukemia.

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It is necessary to determine antibodies to measles virus in the cerebrospinal fluid.

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We found intrathecal synthesis of IgG antibodies to measles virus.

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The disease had a dramatic course and ended in death.

The measles epidemic was observed in Ukraine during 20172019. According to WHO, in Ukraine there was registered the highest number of measles cases in Europe during that period [8].

Measles is characterized by an acute course with fever, maculopapular rash, cough, conjunctivitis and can lead to central nervous system complications (encephalitis, encephalomyelitis) and bronchopulmonary system complications (laryngotracheobronchitis, bronchiolitis, pneumonia).

In immunocompetent patients, viremia ends after the end of clinical signs, in contrast to immunosuppressed individuals, who could develop viremia from one month up to a year.

We have described a case of measles inclusion body encephalitis (MIBE) or subacute measles encephalitis (SME) in an unvaccinated child with an acute lymphoblastic leukemia (ALL). The diagnosis was confirmed by the synthesis of IgG antibodies to the measles virus in the cerebrospinal fluid and by the MRI results. The disease had a dramatic course and ended in death.

Neurological Complications of Measles (Rubeola)

PURPOSE OF REVIEW

Owing to vaccine hesitancy, there has been a resurgence of measles infections in developed countries. Practitioners can expect to see an increase in patients with neurologic complications of measles. These devastating disorders include primary measles encephalitis, acute post measles encephalitis, subacute sclerosing panencephalitis (SSPE), and measles inclusion body encephalitis (MIBE).

RECENT FINDINGS

Although there are many unanswered questions regarding the neurologic complications of measles, recent advances have led to better understanding of the mechanism of the spread of measles within the nervous system, particularly the disruption of F protein function, which raises the possibility of treatment with fusion-inhibiting molecules. Measles and its neurological complications are preventable and must be prevented. Neurologists must educate other clinicians and the public regarding the consequences of inadequate herd immunity to measles. More effective treatments for SSPE and MIBE may be available in the near future, but currently these remain lethal diseases.

Measles-What's Old Is New Again

Measles (rubeola) was once nearly eradicated in the United States. Unfortunately, it has reappeared, with more than three times the number of confirmed cases in 2019 than in 2018. The virus, which produces a distinct rash that appears within days of exposure, can spread quickly and can produce severe complications. There is no cure; treatment is supportive care. Measles was once a minimal concern in the United States due to high vaccination rates. The Centers for Disease Control and Prevention reports that, because of the increase in individuals traveling to countries with high rates of measles and the fact that fewer U.S. children are being immunized against measles, the incidence of measles will likely continue to rise in the United States. It is vital that nurses and other health care providers educate individuals about the importance of the prevention and treatment of measles.

Neuropathology mediated through caspase dependent extrinsic pathway in goat kids naturally infected with PPRV

Peste des petits ruminant (PPR), a highly contagious viral disease of small ruminants, is characterized by erosive stomatitis and pneumo-enteritis. However, its neurovirulence potential as observed with other morbilliviruses has not been fully investigated. The present study describes the neuropathological alterations induced by PPR virus through apoptotic pathway. A total number of 12 carcasses of local breed goat kids of either sex were received for postmortem examination. The clinical history was described as symptoms of mucopurulent nasal discharge, high to low grade fever, erosive stomatitis, dyspnoea and profuse watery diarrhoea followed by mortality of 35 goat kids within a week. The pathoanatomical lesions and immunohistochemical demonstration of PPRV antigen in lungs, intestine, spleen and lymph nodes confirmed PPR disease in goats. Grossly, five brain specimens showed moderate to severe leptomeningeal congestion during necropsy. Microscopically, brain sections showed leptomeningitis and nonsuppurative encephalitis characterized by vascular congestion, haemorrhages in the parenchyma, perivascular cuffing with mild to moderate mononuclear cells (mainly lymphocytes and few macrophages), focal to diffuse microgliosis, neuronal degeneration, satellitosis and neuronophagia. Immunolabelling of viral antigen was observed in the cytoplasm of neurons and glial cells. The RT-PCR amplification of N gene fragment also confirmed the presence of PPRV in the brain. The strong immunoreactivity of Caspase-3, Caspase-8 and comparatively lower expression of caspase-9 along with the absence of any reactivity for Apaf-1 antigen in the brain sections indicated the role of caspase dependent extrinsic pathway in inducing neuropathological changes. The presence of apoptotic neurons in the brain by TUNEL assay further confirmed the apoptosis and strong immunoreactivity of iNOS in neurons which suggested the generation of oxidative stress, that might have induced the apoptosis. The overall findings confirm the neurovirulence potential of PPR virus, via the extrinsic pathway of apoptosis, in natural cases of PPR disease in goat kids.

Oncolytic Measles Virotherapy and Opposition to Measles Vaccination

Recent measles epidemics in US and European cities where vaccination coverage has declined are providing a harsh reminder for the need to maintain protective levels of immunity across the entire population. Vaccine uptake rates have been declining in large part because of public misinformation regarding a possible association between measles vaccination and autism for which there is no scientific basis. The purpose of this article is to address a new misinformed antivaccination argument-that measles immunity is undesirable because measles virus is protective against cancer. Having worked for many years to develop engineered measles viruses as anticancer therapies, we have concluded (1) that measles is not protective against cancer and (2) that its potential utility as a cancer therapy will be enhanced, not diminished, by prior vaccination.

Viral Meningitis and Encephalitis

PURPOSE OF REVIEW

This article discusses meningitis and encephalitis infections caused by viruses, excluding herpes family and human immunodeficiency virus (HIV).

RECENT FINDINGS

The viral infections of the nervous system detailed in this article have no specific treatment other than supportive care. However, many of the viruses discussed are highly preventable by vaccination, proper skin protection against transmitting vectors, and postexposure prophylaxis.

SUMMARY

While meningitis and encephalitis caused by viruses may have some clinical overlap, the management and outcomes can be highly disparate, making distinction between the two imperative. Furthermore, despite their relative rarity in terms of clinical disease, many of the viral infections discussed herein are highly preventable. Given the morbidity and mortality attached to such infections, provider and patient education are the best approach available to prevent these potentially devastating illnesses.

Measles Vaccine Virus RNA in Children More Than 100 Days after Vaccination

Measles vaccines have been in use since the 1960s with excellent safety and effectiveness profiles. Limited data are available on detection of measles vaccine virus (MeVV) RNA in human subjects following vaccination. Available evidence suggests MeVV RNA can be identified up to 14 days after vaccination, with detection beyond this rare. In routine diagnostic testing, we used two real-time reverse transcription-polymerase chain reaction (RT-rPCR) assays targeting M and F genes to identify measles virus (MeV) and MeVV RNA. Confirmatory testing was performed with an N gene RT-rPCR, followed by sequence confirmation of RT-rPCR positives by semi-nested conventional RT-PCR assays targeting portions of the N, H, and L genes. We report detection and confirmation of MeVV RNA from the respiratory tract of 11 children between 100 and 800 days after most recent receipt of measles-containing vaccine. These novel findings emphasize the importance of genotyping all MeV detections and highlight the need for further work to assess whether persistent MeVV RNA represents viable virus and if transmission to close contacts can occur.

Case Report: Subacute Sclerosing Panencephalitis Presenting as Acute Encephalitis

Subacute sclerosing panencephalitis (SSPE) is still a common disease in India which is characterized by a progressive mental decline, myoclonus, periodic encephalographic abnormalities, and raised anti-measles antibody titter in the cerebrospinal fluid. Acute fulminant SSPE is characterized by a rapid course of disease culminating in death, within 6 months. We report of a 10-year-old boy, who came with a 14-day history of continuous involuntary jerky movements of the left half of the body, including the head. There was a highly increased anti-measles IgG antibody titer, both in the cerebrospinal fluid and serum. We conclude that acute rapidly progressive SSPE can present as acute encephalitis syndrome.

Are community health workers cost-effective for childhood vaccination in India?

INTRODUCTION

Accredited Social Health Activists (ASHAs) are female community health workers whose primary role is to promote utilization of primary healthcare services and improve sanitation in rural areas and are financially incentivized for services provided. Prior studies evaluating ASHAs have been largely qualitative, and assess their knowledge, skills, and practice. Globally, there have been very few studies that have quantitatively assessed community health workers. We analyzed the cost effectiveness of ASHAs in facilitating measles vaccination among children under 5 years during 2012-2013.

METHODS

We utilized Markov modeling simulating a cohort of children in villages with and without ASHAs. We extrapolated the health states to a lifetime of 68 years to estimate the effects of ASHA intervention. Measles vaccination rates were obtained from 2013 District Level Household and Facilities Survey 4. Other parameter estimates were obtained from a review of relevant literature.

RESULTS

ASHA intervention was highly cost effective at $162 per DALY averted compared to no ASHA and remained cost effective with the ASHA incentive increased from $2 to $15, across the range of probabilities and cost parameters. Analyses were sensitive to probability of death due to childhood pneumonia, susceptibility to measles after one dose measles vaccine, and probability of pneumonia after measles infection.

CONCLUSION

ASHAs were cost-effective under a wide range of scenarios even when a single health outcome such as measles vaccination was considered. The Government of India and individual state governments of India should consider increasing the incentives provided to ASHAs.

Cavitating Leukoencephalopathy With Posterior Predominance Caused by a Deletion in the APOPT1 Gene in an Indian Boy

A 5-year-old Indian boy presented with subacute onset regression of milestones associated with seizures and spasticity. The symptoms started after an attack of measles. The magnetic resonance imaging (MRI) of the brain showed cavitating leukodystrophy with posterior predominance. Molecular analysis of the APOPT1 gene, a recently described gene associated with mitochondrial leukodystrophy, showed the patient to be homozygous for a 12.82-kilobase deletion, including coding exon 3. Deletion of exon 3 produces a frameshift, predicting the translation of a truncated protein (p.Glu121Valfs*4). The patient was started on mitochondrial cocktail regimen of thiamine, riboflavin, coenzyme Q and carnitine. Although he initially showed some improvement, he died 6 months after the onset of his illness.

Measles vaccination: Threat from related veterinary viruses and need for continued vaccination post measles eradication

Measles virus (MV) is the only human virus within the morbillivirus genus of the Paramyxoviridae. The veterinary members are canine distemper virus (CDV), peste des petits ruminants virus (PPRV), Rinderpest Virus (RPV) as well as the marine morbilliviruses phocine distemper virus (PDV), dolphin morbillivirus (DMV) and porpoise morbillivirus (PMV). Morbilliviruses have a severe impact on humans and animal species. They confer diseases which have contributed to morbidity and mortality of the population on a global scale. There is substantial evidence from both natural and experimental infections that morbilliviruses can readily cross species barriers. Of most concern with regard to zoonosis is the more recently reported fatal infection of primates in Japan and China with strains of CDV which have adapted to this host. The close genetic relationship, shared cell entry receptors and similar pathogenesis between the morbilliviruses highlights the potential consequences of complete withdrawal of MV vaccination after eradication. Therefore, it would be prudent to continue the current MV vaccination. Ultimately development of novel, safe vaccines which have higher efficacy against the veterinary morbilliviruses is a priority. These would to protect the human population long term against the threat of zoonosis by these veterinary viruses.

Morbillivirus Pathogenesis and Virus-Host Interactions

Despite the availability of safe and effective vaccines against measles and several animal morbilliviruses, they continue to cause regular outbreaks and epidemics in susceptible populations. Morbilliviruses are highly contagious and share a similar pathogenesis in their respective hosts. This review provides an overview of morbillivirus history and the general replication cycle and recapitulates Morbillivirus pathogenesis focusing on common and unique aspects seen in different hosts. It also summarizes the state of knowledge regarding virus-host interactions on the cellular level with an emphasis on viral interference with innate immune response activation, and highlights remaining knowledge gaps.

Vaccine platform recombinant measles virus

The classic development of vaccines is lengthy, tedious, and may not necessarily be successful as demonstrated by the case of HIV. This is especially a problem for emerging pathogens that are newly introduced into the human population and carry the inherent risk of pandemic spread in a naïve population. For such situations, a considerable number of different platform technologies are under development. These are also under development for pathogens, where directly derived vaccines are regarded as too complicated or even dangerous due to the induction of inefficient or unwanted immune responses causing considerable side-effects as for dengue virus. Among platform technologies are plasmid-based DNA vaccines, RNA replicons, single-round infectious vector particles, or replicating vaccine-based vectors encoding (a) critical antigen(s) of the target pathogens. Among the latter, recombinant measles viruses derived from vaccine strains have been tested. Measles vaccines are among the most effective and safest life-attenuated vaccines known. Therefore, the development of Schwarz-, Moraten-, or AIK-C-strain derived recombinant vaccines against a wide range of mostly viral, but also bacterial pathogens was quite straightforward. These vaccines generally induce powerful humoral and cellular immune responses in appropriate animal models, i.e., transgenic mice or non-human primates. Also in the recent first clinical phase I trial, the results have been quite encouraging. The trial indicated the expected safety and efficacy also in human patients, interestingly independent from the level of prevalent anti-measles immunity before the trial. Thereby, recombinant measles vaccines expressing additional antigens are a promising platform for future vaccines.

Forgotten but Not Gone: Update on Measles Infection for Hospitalists

Measles (rubeola) continues to be endemic and epidemic in many regions of the world. Measles is primarily a disease of childhood, but it can also affect adult populations, and therefore it is important that both adult and pediatric hospitalist physicians be able to recognize it. Although the disease is rarely encountered in the United States, measles infection can spread rapidly across vulnerable populations. In addition, infected adults can develop complications that may require hospitalization for treatment. This review summarizes the typical clinical course and complications of measles infection, along with recommendations for diagnosis and management for both adult and pediatric hospitalists. Journal of Hospital Medicine 2017;12:472-476.

Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications

Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.

Neuroinvasion and Inflammation in Viral Central Nervous System Infections

Neurotropic viruses can cause devastating central nervous system (CNS) infections, especially in young children and the elderly. The blood-brain barrier (BBB) and the blood-cerebrospinal fluid barrier (BCSFB) have been described as relevant sites of entry for specific viruses as well as for leukocytes, which are recruited during the proinflammatory response in the course of CNS infection. In this review, we illustrate examples of established brain barrier models, in which the specific reaction patterns of different viral families can be analyzed. Furthermore, we highlight the pathogen specific array of cytokines and chemokines involved in immunological responses in viral CNS infections. We discuss in detail the link between specific cytokines and chemokines and leukocyte migration profiles. The thorough understanding of the complex and interrelated inflammatory mechanisms as well as identifying universal mediators promoting CNS inflammation is essential for the development of new diagnostic and treatment strategies.

Subacute sclerosing panencephalitis in pregnancy

We present a case of subacute sclerosing panencephalitis that developed in a previously healthy 29-year-old pregnant woman who had returned from a trip to rural India shortly before the onset of symptoms. She was admitted to hospital at 27 weeks' gestation with a history of cognitive decline and difficulty completing simple tasks. She had no clinical signs of infection. The working diagnosis was autoimmune encephalitis, although extensive investigations did not lead to a final classifying diagnosis. The patient became comatose and developed hypertension, and an emergency caesarean section was done at 31 weeks to deliver the child, who seemed healthy. The patient died about 6 weeks after the onset of symptoms. The patient was found to have had subacute sclerosing panencephalitis at autopsy. In this Grand Round, we review the clinical features and treatment of subacute sclerosing panencephalitis, and the epidemiological and public health aspects of the case.

Measles fusion machinery is dysregulated in neuropathogenic variants

Paramyxoviruses, including the human pathogen measles virus (MV), enter host cells by fusing their viral envelope with the target cell membrane. This fusion process is driven by the concerted actions of the two viral envelope glycoproteins, the receptor binding protein (hemagglutinin [H]) and the fusion (F) protein. H attaches to specific proteinaceous receptors on host cells; once the receptor engages, H activates F to directly mediate lipid bilayer fusion during entry. In a recent MV outbreak in South Africa, several HIV-positive people died of MV central nervous system (CNS) infection. We analyzed the virus sequences from these patients and found that specific intrahost evolution of the F protein had occurred and resulted in viruses that are "CNS adapted." A mutation in F of the CNS-adapted virus (a leucine-to-tryptophan change present at position 454) allows it to promote fusion with less dependence on engagement of H by the two known wild-type (wt) MV cellular receptors. This F protein is activated independently of H or the receptor and has reduced thermal stability and increased fusion activity compared to those of the corresponding wt F. These functional effects are the result of the single L454W mutation in F. We hypothesize that in the absence of effective cellular immunity, such as HIV infection, MV variants bearing altered fusion machinery that enabled efficient spread in the CNS underwent positive selection.

IMPORTANCE

Measles virus has become a concern in the United States and Europe due to recent outbreaks and continues to be a significant global problem. While live immunization is available, there are no effective therapies or prophylactics to combat measles infection in unprotected people. Additionally, vaccination does not adequately protect immunocompromised people, who are vulnerable to the more severe CNS manifestations of disease. We found that strains isolated from patients with measles virus infection of the CNS have fusion properties different from those of strains previously isolated from patients without CNS involvement. Specifically, the viral entry machinery is more active and the virus can spread, even in the absence of H. Our findings are consistent with an intrahost evolution of the fusion machinery that leads to neuropathogenic MV variants.