Hypoxemic respiratory failure complicating nosocomial measles in a healthy host

Measles-induced respiratory distress, air-leak and ARDS

Young infants with measles requiring respiratory support have a significant risk for death and long-term complications. Even in developed countries, the occurrence of spontaneous air-leaks and acute respiratory distress syndrome (ARDS) still represent the most severe clinical presentation in early childhood, with a high fatality rate. A clinical series review from a tertiary university paediatric intensive care unit (PICU) was undertaken. During the 2006-2007 outbreak in Rome, Italy, a young infant presented with ARDS/spontaneous air-leak and needed aggressive ventilatory management and haemodynamic support. Both nebulised iloprost and intravenous pentoxifylline were administered during the acute hypoxaemic phase; the role of this pharmacologic approach in critically ill patients is still under debate. We observed four further cases of respiratory impairment requiring a non-invasive approach. Clinical-radiological findings ranged from interstitial pneumonia to bronchiolitis-like pictures. All patients were imported cases, representing an important epidemiological factor and future medical issue, though they were not malnourished nor affected by chronic diseases. We conclude that early respiratory assessment and timely PICU referral is of mainstem importance in the youngest infants with measles-induced respiratory failure. The protean nature of clinical presentation and the possibility of rapid respiratory deterioration should be highlighted, and infants from immigrant families may represent a susceptible high-risk group.

Viral hazards to and from health care workers

Much attention has been directed towards nosocomial transmission of viruses as a result of clear evidence of patient-to-staff and staff-to-patient transmission of the blood-borne viruses HIV and hepatitis B virus. Although the relatively long incubation periods of these viruses, together with the frequency of asymptomatic infections, renders problems for surveillance it has been possible to study modes of transmission and levels of risk over a number of years. Information on trends of incidence of other nosocomial virus infections has been difficult to obtain for a number of reasons. Often, an outbreak in the health care setting parallels an epidemic in the community. Although it may be possible to define nosocomial transmission from recording dates of onset of illness relative to admission date and, at times, demonstrate circulation of a common strain by molecular techniques, the relative contributions of patient-to-staff and staff-to-patient transmission may be difficult to clarify. In this review, details are presented of the major viruses associated with nosocomial transmission with examples of infections to and from staff where these have occurred. The major defences against patient-to-staff and staff-to-patient transmission are awareness of potential risks, education and adherence to infection control policies, immunization of staff, effective decontamination and sterilization and the adoption of 'Universal Precautions' in patient care. In addition, there may be occasions when additional measures should be considered including isolation, cohorting and the use of specific chemo- and immunoprophylaxis.