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Zrzavy T, Kollaritsch H, Rommer PS, Boxberger N, Loebermann M, Wimmer I, Winkelmann A, Zettl UK. Vaccination in Multiple Sclerosis: Friend or Foe? Front Immunol 2019; 10:1883. [PMID: 31440255 PMCID: PMC6693409 DOI: 10.3389/fimmu.2019.01883] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 07/24/2019] [Indexed: 12/20/2022] Open
Abstract
Multiple sclerosis (MS) is a debilitating disease of the central nervous systems (CNS). Disease-modifying treatments (including immunosuppressive treatments) have shown positive effects on the disease course, but are associated with systemic consequences on the immune system and may increase the risk of infections and alter vaccine efficiency. Therefore, vaccination of MS patients is of major interest. Over the last years, vaccine hesitancy has steadily grown especially in Western countries, partly due to fear of sequelae arising from vaccination, especially neurological disorders. The interaction of vaccination and MS has been discussed for decades. In this review, we highlight the immunology of vaccination, provide a review of literature and discuss the clinical consideration of MS, vaccination and immunosuppression. In conclusion, there is consensus that MS cannot be caused by vaccines, neither by inactivated nor by live vaccines. However, particular attention should be paid to two aspects: First, in immunocompromised patients, live vaccines may lead to a stronger immune reaction with signs of the disease against which the patients have been vaccinated, albeit in weakened form. Second, protection provided by vaccination should be controlled in patients who have been vaccinated while receiving immunomodulatory or immunosuppressive treatment. In conclusion, there is evidence that systemic infections can worsen MS, thus vaccination will lower the risk of relapses by reducing the risk of infections. Therefore, vaccination should be in general recommended to MS patients.
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Affiliation(s)
- Tobias Zrzavy
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Herwig Kollaritsch
- Institute of Specific Prophylaxis and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Nina Boxberger
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
| | - Micha Loebermann
- Department of Tropical Medicine and Infectious Diseases, University of Rostock, Rostock, Germany
| | - Isabella Wimmer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological Section, University of Rostock, Rostock, Germany
- Department of Neurology, University of Rostock, Rostock, Germany
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Chen Y, Ma F, Xu Y, Chu X, Zhang J. Vaccines and the risk of acute disseminated encephalomyelitis. Vaccine 2018; 36:3733-3739. [PMID: 29784468 DOI: 10.1016/j.vaccine.2018.05.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/12/2018] [Accepted: 05/14/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is important to examine the risk of Acute disseminated encephalomyelitis (ADEM) after vaccination. METHODS We conducted a nested case-control study between January 2011 and December 2015. Four controls per case were matched for age, gender, address. An independent expert committee validated the diagnoses of cases and controls. Data on vaccinations were obtained from computerized vaccination records. The analyses were conducted with the use of conditional logistic regression. RESULTS The analyses include 272 cases of ADEM and 1096 controls. No increase in the risk of ADEM was observed for vaccination against hepatitis B, influenza, polio(live), diphtheria, pertuss(acellular), tetanusis, measles, mumps, rubella, Japanese Encephalitis, meningitis, hepatitis A, varicella and rabies vaccines. Vaccine was associated with a statistically significant increase in risk in the 31-60-day exposure interval (OR, 4.04 [95% CI, 1.07-12.69]), but not the 0-30 and 61-180-day interval. There was no association between vaccine received and the recurrence of ADEM. CONCLUSIONS Findings from the present study do not demonstrate an association of vaccines with an increased risk of ADEM and its recurrence among either paediatric (≤18 years) or adult (>18 years) individuals within the 180 days after vaccinations. The finding in children in the 31-60 day risk interval is likely coincidental and was not confirmed in separate self-control analyses.
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Affiliation(s)
- Yong Chen
- Department of Expanded Program on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, China.
| | - Fubao Ma
- Department of Expanded Program on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, China
| | - Yuanling Xu
- Department of Neurology, Nanjing Brain Hospital, China.
| | - Xuhua Chu
- Department of Neurology, Jiangsu Provincial People's Hospital, China.
| | - Jinlin Zhang
- Department of Expanded Program on Immunization, Jiangsu Provincial Center for Disease Control and Prevention, China.
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D'Costa DF, Cooper A, Pye IF. Transverse Myelitis following Cholera, Typhoid and Polio Vaccination. J R Soc Med 2018; 83:653. [PMID: 2286971 PMCID: PMC1292867 DOI: 10.1177/014107689008301022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- D F D'Costa
- Department of Neurology, Leicester Royal Infirmary
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4
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Vaccine-associated inflammatory diseases of the central nervous system: from signals to causation. Curr Opin Neurol 2018; 29:362-71. [PMID: 27023738 DOI: 10.1097/wco.0000000000000318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW As the most cost-effective intervention in preventive medicine and as a crucial element of any public health program, vaccination is used extensively with over 90% coverage in many countries. As approximately 5-8% of the population in developed countries suffer from an autoimmune disorder, people with an autoimmune disease are most likely to be exposed to some vaccines before or after the disease onset. In fact, a number of inflammatory disorders of the central nervous system have been associated with the administration of various vaccines. These adverse events, be they spurious associations or genuine reactions to the vaccine, may lead to difficulties in obtaining public trust in mass vaccination programs. There is, thus, an urgent need to understand whether vaccination triggers or enhances autoimmune responses. RECENT FINDINGS By reviewing vaccine-associated inflammatory diseases of the central nervous system, this study describes the current knowledge on whether the safety signal was coincidental, as in the case of multiple sclerosis with several vaccines, or truly reflected a causal link, as in narcolepsy with cataplexy following pandemic H1N1 influenza virus vaccination. SUMMARY The lessons learnt emphasize a central role of thorough, ideally prospective, epidemiological studies followed, if the signal is deemed plausible or real, by immunological investigations.
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Baxter R, Lewis E, Goddard K, Fireman B, Bakshi N, DeStefano F, Gee J, Tseng HF, Naleway AL, Klein NP. Acute Demyelinating Events Following Vaccines: A Case-Centered Analysis. Clin Infect Dis 2016; 63:1456-1462. [PMID: 27585798 DOI: 10.1093/cid/ciw607] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/25/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Case reports have suggested that vaccines may trigger transverse myelitis (TM) or acute disseminated encephalomyelitis (ADEM), but the evidence for a causal association is inconclusive. We analyzed the association of immunization and subsequent development of TM or ADEM. METHODS We identified all cases of TM and ADEM in the Vaccine Safety Datalink population. Using a case-centered method, we compared vaccination of each case to vaccination of all matched persons in the study population, who received the same type of vaccine, with respect to whether or not their vaccination occurred during a predetermined exposure interval. We calculated a risk difference (excess risk) of TM and ADEM for each vaccine. RESULTS Following nearly 64 million vaccine doses, only 7 cases of TM and 8 cases of ADEM were vaccinated during the primary exposure window 5-28 days prior to onset. For TM, there was no statistically significant increased risk of immunization. For ADEM, there was no statistically significant increased risk following any vaccine except for Tdap (adolescent and adult tetanus, reduced diphtheria, acellular pertussis) vaccine. Based on 2 exposed cases, the odds ratio for Tdap exposure 5-28 days prior to ADEM onset was 15.8 (95% confidence interval [CI], 1.2-471.6; P = .04), and the estimated excess risk was 0.385 (95% CI, -.04 to 1.16) cases per million doses. CONCLUSIONS We found no association between TM and prior immunization. There was a possible association of ADEM with Tdap vaccine, but the excess risk is not likely to be more than 1.16 cases of ADEM per million vaccines administered.
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Affiliation(s)
- Roger Baxter
- Northern California Kaiser Permanente Vaccine Study Center, Oakland
| | - Edwin Lewis
- Northern California Kaiser Permanente Vaccine Study Center, Oakland
| | - Kristin Goddard
- Northern California Kaiser Permanente Vaccine Study Center, Oakland
| | - Bruce Fireman
- Northern California Kaiser Permanente Vaccine Study Center, Oakland
| | | | - Frank DeStefano
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julianne Gee
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Allison L Naleway
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Nicola P Klein
- Northern California Kaiser Permanente Vaccine Study Center, Oakland
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6
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Agmon-Levin N, Kivity S, Szyper-Kravitz M, Shoenfeld Y. Transverse myelitis and vaccines: a multi-analysis. Lupus 2010; 18:1198-204. [PMID: 19880568 DOI: 10.1177/0961203309345730] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transverse myelitis is a rare clinical syndrome in which an immune-mediated process causes neural injury to the spinal cord. The pathogenesis of transverse myelitis is mostly of an autoimmune nature, triggered by various environmental factors, including vaccination. Our aim here was to search for and analyze reported cases of transverse myelitis following vaccination. A systematic review of PubMed, EMBASE and DynaMed for all English-language journals published between 1970 and 2009 was preformed, utilizing the key words transverse myelitis, myelitis, vaccines, post-vaccination, vaccination and autoimmunity. We have disclosed 37 reported cases of transverse myelitis associated with different vaccines including those against hepatitis B virus, measles-mumps-rubella, diphtheria-tetanus-pertussis and others, given to infants, children and adults. In most of these reported cases the temporal association was between several days and 3 months, although a longer time frame of up to several years was also suggested. Although vaccines harbor a major contribution to public health in the modern era, in rare cases they may be associated with autoimmune phenomena such as transverse myelitis. The associations of different vaccines with a single autoimmune phenomenon allude to the idea that a common denominator of these vaccines, such as an adjuvant, might trigger this syndrome.
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Affiliation(s)
- N Agmon-Levin
- Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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7
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Giovanetti F. Travel medicine interventions and neurological disease. Travel Med Infect Dis 2006; 5:7-17. [PMID: 17161313 DOI: 10.1016/j.tmaid.2006.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Accepted: 03/16/2006] [Indexed: 01/04/2023]
Abstract
As a consequence of increased mobility worldwide, persons with underlying medical conditions set out on a journey more often than in the past. Among pre-existing medical conditions, some neurological diseases, including multiple sclerosis and other demyelinating diseases, Guillain-Barré syndrome and myasthenia gravis often create management problems to travel medicine practitioners. There is some concern that these conditions could be worsened either by naturally acquired infections or by some travel medicine interventions. The aim of this review is to suggest a practical approach to each of these conditions and to examine the feasibility and the impact of travel medicine interventions on the underlying disease.
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Affiliation(s)
- Franco Giovanetti
- Azienda Sanitaria Locale Alba Bra, Dipartimento di Prevenzione, via Vida 10, 12051 Alba, Italy.
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8
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Zanoni G, Nguyen TMD, Destefani E, Masala L, Nardelli E, Tridente G. Transverse myelitis after vaccination. Eur J Neurol 2002; 9:696-7. [PMID: 12453095 DOI: 10.1046/j.1468-1331.2002.00447_9.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Tsuru T, Mizuguchi M, Ohkubo Y, Itonaga N, Momoi MY. Acute disseminated encephalomyelitis after live rubella vaccination. Brain Dev 2000; 22:259-61. [PMID: 10838115 DOI: 10.1016/s0387-7604(00)00102-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report here a case involving a 14-year-old boy who developed acute disseminated encephalomyelitis following live rubella vaccination. The patient became febrile and began to experience nuchal pain 16 days after the immunization. By 22 days after immunization, he experienced difficulty in walking. By 24 days, he had developed tetraparesis with retention of urine, and total sensory loss below the Th1 dermatomal level. He was febrile at this point and showed nuchal rigidity and Lhermitte's sign. Cerebrospinal fluid examination revealed elevated cell counts, protein level, and myelin basic protein. T2-weighted magnetic resonance imaging detected high intensity lesions in the bilateral cerebral white matter and cervical spinal cord. Following the administration of intravenous corticosteroids, the patient's clinical symptoms improved rapidly.
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Affiliation(s)
- T Tsuru
- Department of Pediatrics, Jichi Medical School, Tochigi, Japan.
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10
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Bakshi R, Mazziotta JC. Acute transverse myelitis after influenza vaccination: magnetic resonance imaging findings. J Neuroimaging 1996; 6:248-50. [PMID: 8903080 DOI: 10.1111/jon199664248] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Descriptions in the literature of magnetic resonance imaging (MRI) findings in post-vaccination myelitis are scarce. Described here is a case of acute transverse myelitis that occurred after administration of an influenza vaccination. T1-weighted MRIs showed diffuse, fusiform spinal cord enlargement, extending from C-3 to rostral thoracic levels. Intramedullary lesions containing increased T2 signal were found in the areas of cord enlargement. The involvement on MRI was profound, extending far rostral to the level of the discrete clinical myelopathy. The lesions did not enhance after contrast administration. The patient had a complete long-term recovery of neurological function. This represents the first report of MRI findings in acute transverse myelitis after influenza vaccination.
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Affiliation(s)
- R Bakshi
- Department of Neurology, UCLA School of Medicine, USA
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11
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Friedrich F, Filippis AM, Schatzmayr HG. Sabin-related poliovirus vaccine strains isolated from transverse myelitis cases in Brazil. Rev Inst Med Trop Sao Paulo 1995; 37:543-5. [PMID: 8731270 DOI: 10.1590/s0036-46651995000600013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- F Friedrich
- Departamento de Virologia, Instituto Oswaldo Cruz, Rio de Janeiro, Brasil
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12
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Joyce KA, Rees JE. Transverse myelitis after measles, mumps, and rubella vaccine. BMJ (CLINICAL RESEARCH ED.) 1995; 311:422. [PMID: 7640590 PMCID: PMC2550491 DOI: 10.1136/bmj.311.7002.422a] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- K A Joyce
- Hurstwood Park Neurological Centre, Haywards Heath, West Sussex
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14
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Valensin PE, Rossolini GM, Cusi MG, Zanchi A, Cellesi C, Rossolini A. Specific antibody patterns over a two-year period after rubella immunization with RA 27/3 live attenuated vaccine. Vaccine 1987; 5:289-94. [PMID: 3433917 DOI: 10.1016/0264-410x(87)90154-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Screening for rubella antibodies was carried out on 1557 schoolgirls aged 9-20. Of seronegative subjects 70% (442/631) were immunized with RA 27/3 rubella vaccine and some of the vaccinees underwent a serological and clinical follow-up over a two year period. Adverse reactions occurred in 27% of vaccinees, usually 1-2 weeks after immunization; late reactions were never observed. The vaccine-induced seroconversion rate evaluated at 4-5 weeks after immunization was 99.7%. Both one and two years after immunization the seropositivity rate of vaccinees was 100%. The maximum geometric mean antibody titre (GMT) was observed at 4-5 weeks after vaccination and a significant GMT decrease was evident on both the following annual controls. Specific antibody patterns in vaccinees were highly variable and in a small number of subjects a remarkable antibody titre decrease was noticed.
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Affiliation(s)
- P E Valensin
- Institute of Microbiology, University of Siena, Italy
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15
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Heilbronn YD, Tovi F, Hirsch M, Ronen J. Transverse cervical myelopathy: an unusual complication of retropharyngeal abscess. HEAD & NECK SURGERY 1984; 6:1051-3. [PMID: 6469656 DOI: 10.1002/hed.2890060612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Retropharyngeal abscess complicated by suppuration in the central nervous system, intra- or extraaxial, is rare. Acute transverse myelopathy complicating a retropharyngeal abscess may be more frequent than epidural spinal abscess and usually affects the thoracic cord. Therefore, the occurrence of acute high cervical transverse myelopathy is rarely encountered and warrants reporting. The need for neuroradiologic diagnostic evaluation is emphasized in order to rule out a surgically treatable lesion.
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Van Alstyne D, Paty DW. The effect of dibutyryl cyclic AMP on restricted replication of rubella virus in rat glial cells in culture. Virology 1983; 124:173-80. [PMID: 6297151 DOI: 10.1016/0042-6822(83)90301-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Normal adult rat glial (RG) cells in culture have been shown to restrict rubella virus (RV) replication, permitting the synthesis of only five of the seven intracellular viral polypeptides associated with a normal, productive infection. Recently uninfected RG cells have been reported to differentiate into mature glia in the presence of dibutyryl cyclic AMP (dB-cAMP), suggesting that the RG cells may be a continuous cell line of undifferentiated glioblasts. This communication describes the effect of dB-cAMP on rubella-infected RG cells. Following exposure to dB-cAMP, RV antigens could be demonstrated in the cytoplasm of the differentiating glioblasts, all seven intracellular RV polypeptides could be detected following immune precipitation, slab gel electrophoresis, and autoradiography, and infectious progeny virions could be titered from the tissue culture medium. These data indicate that dB-cAMP promotes glioblast maturation and a concomitant activation of RV replication.
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Abstract
Vaccines prepared from whole, killed organisms (pertussis and possibly influenza) may cause neurological allergic reactions producing encephalopathy. These reactions are characterized by acute, monophasic demyelinative processes and occur with no greater frequency than 1 per 100,000 vaccine recipients; onset is within 4 days of immunization, and recovery is usually complete. No evidence suggests that these vaccines produce an insidious, progressive encephalopathy. Only with the swine influenza program of 1976 has Guillain-Barré syndrome appeared to follow immunization. Vaccines prepared from live-attenuated viruses (measles, mumps, rubella, and trivalent oral poliovirus) can cause symptomatic viral infection of the nervous system, including measles encephalitis, which occurs in 1 of 1,000,000 vaccine recipients; rubella neuritis, in less than 1 of 10,000 recipients; and paralytic poliomyelitis, in 1 of 3,000,000 vaccine recipients or their close contacts. A cause-and-effect relationship between immunization and brachial plexus neuritis, acute transverse myelitis, and cranial neuropathies has been suggested but never proved.
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19
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Pope DD, Van Alstyne D. Evidence for restricted replication of Rubella virus in rat glial cells in culture. Virology 1981; 113:776-80. [PMID: 7269259 DOI: 10.1016/0042-6822(81)90207-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Tal Y, Crichton JU, Dunn HG, Dolman CL. Spinal cord damage: a rare complication of purulent meningitis. ACTA PAEDIATRICA SCANDINAVICA 1980; 69:471-4. [PMID: 7446096 DOI: 10.1111/j.1651-2227.1980.tb07116.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Three cases of spinal cord damage following acute bacterial meningitis are described. Two children survived with neurological sequelae, while one died. Autopsy showed extensive spinal cord necrosis. The possible mechanisms for this rare complication are discussed and a possible connection with transient cardiorespiratory arrest is suggested.
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Abstract
The possibility that acute disseminated encephalomyelitis (ADEM) and epidemic myalgic encephalomyelitis ('epidemic neuromyasthenia') may share a common pathogenesis is examined and many factors common to the two diseases are described. It is suggested that further study of ADEM may help our understanding of epidemic myalgic encephalomyelitis.
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Callaghan N, Feely M, Walsh B. Relapsing neurological disorder associated with rubella virus infection in two sisters. J Neurol Neurosurg Psychiatry 1977; 40:1117-9. [PMID: 599358 PMCID: PMC492911 DOI: 10.1136/jnnp.40.11.1117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A disseminated relapsing neurological disorder presented simultaneously in two sisters. Encephalitic features were present in one case. The illness was associated with a significant increase in rubella specific IgM in both sisters. Despite the absence of a rubella rash, this increase would be compatible with a recent infection by the rubella virus as a basis for the illness, and the persistent elevation, with active antigenic stimulation. It is suggested that both patients might represent the clinical manifestations of perivenous demyelination caused by the rubella virus, which, in view of the relapsing nature of the illness, has progressed to plaque formation.
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