Patients With Subacute Sclerosing Panencephalitis in Japan: A 2022 Nationwide Survey

BACKGROUND

In Japan, the incidence of subacute sclerosing panencephalitis (SSPE) has reduced; however, the medical conditions and factors associated with disease progression remain unclear.

METHODS

A nationwide survey of SSPE was conducted using a questionnaire in 2022. We conducted a descriptive analysis of the patients with SSPE in 2022 and Cox proportional hazards analyses for disease progression. We compared the patients with SSPE with those in a 2007 survey.

RESULTS

A total of 37 surviving patients with SSPE were enrolled [median age: 32 years (range: 16-52 years)]. No new cases have been identified since 2017 in the survey. Jabbour stage IV was the most common stage (66.7%). The hazard ratios (95% confidence intervals) of male sex and age at the time of measles infection (years) were 2.56 (1.13-5.76) and 0.57 (0.34-0.93), respectively. Compared with those in 2007, the proportion of patients in hospitals decreased from 13.7% to 2.7%, whereas that of patients in nursing facilities increased from 17.6% to 29.7%. The proportions of patients prescribed inosine pranobex, interferon and ribavirin at the time of the survey decreased from 96.1% to 79.4%, 74.8% to 14.3% and 25.3% to 0%, respectively. The proportions of patients with gastrostomy, tracheostomy and ventilator use increased from 5.9% to 69.7%, 23.3% to 60.0% and 10.8% to 32.4%, respectively.

CONCLUSIONS

Decreased measles cases in Japan reduced new SSPE cases. However, surviving patients in 2022 had advanced disease stages and needed medical care. Male sex and early measles infection were significantly associated with disease progression.

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.

Subacute Sclerosing Panencephalitis in Children: The Archetype of Non-Vaccination

Subacute sclerosing panencephalitis (SSPE) is a late complication of measles virus infection that occurs in previously healthy children. This disease has no specific cure and is associated with a high degree of disability and mortality. In recent years, there has been an increase in its incidence in relation to a reduction in vaccination adherence, accentuated by the COVID-19 pandemic. In this article, we take stock of the current evidence on SSPE and report our personal clinical experience. We emphasise that, to date, the only effective protection strategy against this disease is vaccination against the measles virus.

Epidemiology of subacute sclerosing panencephalitis (SSPE) in Germany from 2003 to 2009: a risk estimation

Subacute sclerosing panencephalitis (SSPE) is a fatal long-term complication of measles infection. We performed an estimation of the total number of SSPE cases in Germany for the period 2003 to 2009 and calculated the risk of SSPE after an acute measles infection. SSPE cases were collected from the Surveillance Unit for Rare Paediatric Diseases in Germany and the Institute of Virology and Immunobiology at the University of Würzburg. The total number of SSPE cases was estimated by capture-recapture analysis. For the period 2003 to 2009, 31 children with SSPE who were treated at German hospitals were identified. The capture-recapture estimate was 39 cases (95% confidence interval: 29.2–48.0). The risk of developing SSPE for children contracting measles infection below 5 years of age was calculated as 1∶1700 to 1∶3300. This risk is in the same order of magnitude as the risk of a fatal acute measles infection.

Subacute sclerosing panencephalitis in papua new guinean children: the cost of continuing inadequate measles vaccine coverage

INTRODUCTION

subacute sclerosing panencephalitis (SSPE) is a late, rare and usually fatal complication of measles infection. Although a very high incidence of SSPE in Papua New Guinea (PNG) was first recognized 20 years ago, estimated measles vaccine coverage has remained at ≤ 70% since and a large measles epidemic occurred in 2002. We report a series of 22 SSPE cases presenting between November 2007 and July 2009 in Madang Province, PNG, including localized clusters with the highest ever reported annual incidence.

METHODOLOGY/PRINCIPAL FINDINGS

as part of a prospective observational study of severe childhood illness at Modilon Hospital, the provincial referral center, children presenting with evidence of meningo-encephalitis were assessed in detail including lumbar puncture in most cases. A diagnosis of SSPE was based on clinical features and presence of measles-specific IgG in cerebrospinal fluid and/or plasma. The estimated annual SSPE incidence in Madang province was 54/million population aged <20 years, but four sub-districts had an incidence >100/million/year. The distribution of year of birth of the 22 children with SSPE closely matched the reported annual measles incidence in PNG, including a peak in 2002.

CONCLUSIONS/SIGNIFICANCE

SSPE follows measles infections in very young PNG children. Because PNG children have known low seroconversion rates to the first measles vaccine given at 6 months of age, efforts such as supplementary measles immunisation programs should continue in order to reduce the pool of non-immune people surrounding the youngest and most vulnerable members of PNG communities.

[Epidemiology of subacute sclerosing panencephalitis in Okinawa, Japan (1977-2005)]

The epidemiology of subacute sclerosing panencephalitis (SSPE) has changed since the introduction of measles immunization in 1970's. We studied the incidence of SSPE in Okinawa. There were 22 cases (16 males and 6 females) of SSPE from 1977 to 2005 in Okinawa. The incidence was 0.63 per million population per year from 1977 to 1986, 0 from 1987 to 1993, 1.17 from 1994 to 1999 and 0.75 from 2000 to 2005. Twenty-one SSPE patients had a history of non-immunized measles and 19 of them (90%) had measles infection under 2 years of age. There were measles epidemic every 2-5 years in Okinawa. Ten of 21 cases contracted measles in 1990-1991. The percentage of patients with measles infection under 2 years of age during measles epidemics ranged from 46% to 56%. Early measles infection (under 2 years of age) is a risk factor for SSPE. Routine measles immunization to prevent measles infection is very important for the prevention of SSPE.

Subacute sclerosing panencephalitis in a tertiary care centre in post measles vaccination era

This study was conducted to observe the impact of measles vaccination on the epidemiology of subacute sclerosing panencephalitis (SSPE) in the post measles vaccination era. This is a retrospective study from a tertiary care hospital, covering a ten year period starting a decade after the introduction of the national measles immunization programme in India. We analyzed 458 serologically confirmed SSPE cases. These patients had a high cerebrospinal fluid: serum anti-measles antibody ratio. The male to female ratio in the present study was 4.4:1. The mean age at onset of SSPE was 13.3 years, showing an increase in mean age at onset of SSPE. Clinical and other demographic details, available from 72 in-patients, are discussed in this report. Of these, a history of measles could be elicited in 34 cases. Mean latent period between measles infection and onset of SSPE was 7.8 years. Six patients gave a history of measles vaccination. A sizable percentage (15.5 %) of the patients was > or = 18 years old and considered to have adult onset SSPE. The incidence of SSPE continues to be high and this report highlights the need for further strengthening routine measles immunization coverage.

[Epidemiological aspects of SSPE]

SSPE is neurodegenerative complication of slow measles infection in young children. In developing countries, SSPE has become rare disease because of widespread immunization for measles. However, in under developing countries, it is not rare disease. In Japan, widespread measles vaccination started in 1978. From 1981 SSPE cases declined to about 5 patients per year. We studied 114 cases with SSPE who were still alive in 2003. Incidence of SSPE elevated to near 10 cases per year in 1993-1998 coincident with decline of the rate of immunization for measles. After 1999, the incidence is under 5 cases per year. The immunization rate of young children increased to over 90%, SSPE will become rare disease near future. Future problem will be adult or infant onset of SSPE because of decreasing of anti measles virus titer, SSPE in immunosuppressive state including AIDS or post measles vaccination SSPE.

Serum levels of matrix metalloproteinase-9 and tissue inhibitors of metalloproteinases 1 in subacute sclerosing panencephalitis

We determined the relationship between the serum concentrations of matrix metalloproteinase-9 (MMP-9) and tissue inhibitors of metalloproteinases 1 (TIMP-1) in 33 patients with subacute sclerosing panencephalitis (SSPE) to investigate the function of the blood-brain-barrier (BBB) in SSPE. Serum MMP-9 and TIMP-1 levels were measured by ELISA. Serum MMP-9 levels and MMP-9/TIMP-1 ratios of SSPE patients in Papua New Guinea (n = 24), and those in Japan (n = 9) were significantly higher than the each control (MMP-9, p = 0.0390, and p = 0.0023, respectively; MMP-9/TIMP-1, p = 0.0319, and p = 0.0009, respectively). Serum MMP-9 levels and MMP-9/TIMP-1 ratios of SSPE patients with Jabbour stage III (n = 13) were significantly higher than those with Jabbour stage II (n = 18) (p = 0.003, and p = 0.0412, respectively). There were no significant differences of serum TIMP-1 levels between the SSPE patients and controls. High serum MMP-9 and MMP-9/TIMP-1 levels will promote brain invasion through the BBB by immunocompetent cells in the blood. Our findings suggest that the balance of serum MMP-9 and TIMP-1 levels modulate the inflammatory cascade of SSPE.

Subacute sclerosing panencephalitis: is there something different in the younger children?

Subacute sclerosing panencephalitis is a rare, slow viral infection caused by a defective measles virus. Although it is a rare disease, it is still important in developing countries. The onset is generally between the ages of 5-15 years. We reported the clinical and laboratory profile and nature of 9 patients under the age of 4 years with SSPE. Although it is known that a few patients with SSPE have an acute and rapidly fulminating course, in this study rate of progression was rapidly progressive in 6 patients and progressive in 3 of them on admission. Unfortunately, 4 of them were lost to follow up because of address and/or telephone number alterations. Although the number of patients in this study is not sufficient, we suggest that SSPE patients under the age of 4 years have a poor prognosis as a result of progressive or rapidly progressive course despite medical treatment.

Long term survival in subacute sclerosing panencephalitis: an enigma

BACKGROUND

Subacute sclerosing panencephalitis (SSPE) usually has a progressive stereotypic downhill course and results in premature death. Long-term stabilization or remission is exceptional.

OBJECTIVE

To analyze the profile of patients with a relatively 'benign' course who survive beyond 3 years.

DESIGN

Descriptive analysis of 19 (16 male, 3 females)/307 (6.2%) patients with benign course who were evaluated at NIMHANS between January 1995 and December 2004. Their diagnosis was based on characteristic myoclonic jerks, elevated antibody titers against measles virus in CSF and periodic complexes in EEG.

RESULTS

The mean age at onset of symptoms was 11.7+/-3.9 years and mean duration of follow-up from first symptom was 5.9+/-3.1 years (3-13.8 years). Their initial symptoms were seizures (7), myoclonus (6), visual disturbances (4), behavioral changes (1) and cognitive impairment (1). These patients had varied clinical course: stabilization in different stages for 6 months to 5 years (13), remissions for 6 months to 9 years and reversal of staging with functional recovery from being bed bound to ambulant (8). Their diagnosis was often delayed. Small sample size did not permit to analyze the influence of possible disease modifying agents used in 10 patients (isoprenosine-3, amantidine-4, oral steroids-4, methylprednisolone-1, intravenous immunoglobulin-1).

CONCLUSIONS

Our observations suggest that SSPE may have a highly variable clinical course and warrants cautious approach for counseling at initial evaluation and while interpreting beneficial effect of disease modifying agent(s). There is a need to explore prognostic marker(s).

Measles-associated encephalopathy in children with renal transplants

Two children, boys of 8 and 13 years, presented with measles-associated encephalopathy several years after kidney transplantation for congenital nephrotic syndrome. In the absence of prior clinical measles, the neurological symptoms initially eluded diagnosis, but retrospective analysis of stored samples facilitated the diagnosis of measles-associated encephalopathy without recourse to biopsy of deep cerebral lesions. Each had received a single dose of measles mumps and rubella vaccine before 12 months of age. Prior vaccination, reduction of immunosuppression and treatment with intravenous immunoglobulin and ribavirin may have contributed to their survival. Persistent measles virus RNA shedding, present in one child, was not controlled by treatment with i.v. ribavirin. Two years later, both patients continue to have functioning allografts with only minimal immunosuppression. These cases illustrate the difficulty in diagnosing measles-associated encephalopathy in the immunocompromised host, even in the era of molecular diagnostics, and highlight the renewed threat of neurological disease in communities with incomplete herd immunity.

Adult onset subacute sclerosing panencephalitis: clinical profile of 39 patients from a tertiary care centre

Clinical and laboratory characteristics of 39 patients with adult onset subacute sclerosing panencephalitis (SSPE) are described and compared to those of juvenile onset patients regarding preceding measles, age at onset, gender, interval between onset and diagnosis, clinical profile, and course during follow up. Diagnosis was based on clinical and electroencephalographic findings and raised anti-measles antibody titres in cerebrospinal fluid. Mean age at SSPE symptom onset was 20.9+/-4.9 years and mean interval from onset to diagnosis was 6.3+/-9.6 months. Referral diagnosis was accurate in only 12 patients. Presenting symptoms included myoclonus, behavioural changes, seizures, and cognitive, visual, and extrapyramidal disturbance. All patients received symptomatic therapy; 19 also received disease modifying agents. Five of seven pregnant women had successful deliveries. The follow-up period varied widely (maximum 60 months, median 9 months). The profile of adult onset SSPE did not differ from the rest of the cohort, except for a longer interval between measles infection and symptom onset (p<0.0001). SSPE in adults poses diagnostic challenges for clinicians. A high index of suspicion and appropriate investigations are necessary for early diagnosis and counselling.

Subacute sclerosing panencephalitis surveillance study in Istanbul

The exact incidence rate of subacute sclerosing panencephalitis (SSPE) in Turkey (and in Istanbul) is not known. We have conducted an active surveillance study to determine the epidemiological characteristics and the incidence rate of SSPE in Istanbul between the dates July 1, 2002 and July 1, 2004. We found that the incidence of SSPE in Istanbul is 2 per million. By logistic regression analysis, risk factors in SSPE development are determined as being at younger ages (OR: 1.199, 95%CI=1.047-1.372, P=0.009), living in crowded households (OR: 1.430, 95%CI=1.039-1.968, P=0.028), low education level of the mother (OR: 0.123, 95%CI=0.034-0.447, P=0.001), low household income (OR: 0.413, 95%CI=0.234-0.728, P=0.002), infant's being born out of Marmara region (Istanbul is in Marmara region of Turkey) (OR: 0.358, 95%CI: 0.172-0.746, P=0.006), infant's not being vaccinated against measles (OR: 0.495, 95%CI: 0.312-0.786), infant's having had measles before (OR: 0.235, 95%CI: 0.135-0.411). As a result, it is found in this study that SSPE is mostly related to having measles infection, and measles vaccination is found to be highly protective against SSPE. This is the first epidemiological study in SSPE from Turkey that conveys the incidence rate in Istanbul.

Subacute sclerosing panencephalitis: results of the Canadian Paediatric Surveillance Program and review of the literature

BACKGROUND

Subacute Sclerosing Panencephalitis (SSPE) is so rare in developed countries with measles immunization programs that national active surveillance is now needed to capture sufficient number of cases for meaningful analysis of data. Through the Canadian Paediatric Surveillance Program (CPSP), the SSPE study was able to document a national incidence and determine the epidemiology of affected Canadian children.

METHODS

Between 1997 and 2000, the CPSP surveyed monthly 1978 to 2294 Canadian pediatricians and sub-specialists for SSPE cases. The response rate varied from 82-86% over those years.

RESULTS

Altogether, four SSPE cases were reported to the CPSP: one case before, two during and one after the study period. The incidence of SSPE in Canadian children was 0.06/million children/year. Of the four cases, diagnosed between ages four and 17 years, three children had measles infection in infancy. All children showed a progressive course of dementia, loss of motor skills and epilepsy. Two children were treated with isoprinosine and intraventricular interferon but died in less than three years from disease onset. One child did not have any treatment and died after seven years of illness. One child received intraventricular ribavirin and remains alive, but markedly impaired, nine years following diagnosis.

CONCLUSION

The CPSP has demonstrated that Canadian paediatricians and paediatric neurologists may encounter cases of SSPE. This report highlights the clinical course of affected Canadian children and provides a review of the disease and its management.

Subacute sclerosing panencephalitis: more cases of this fatal disease are prevented by measles immunization than was previously recognized

BACKGROUND

The most severe sequela of measles virus infection is subacute sclerosing panencephalitis (SSPE), a fatal disease of the central nervous system that generally develops 7-10 years after infection. From 1989 through 1991, a resurgence of measles occurred in the United States, with 55,622 cases of measles reported. The purpose of the present study was to identify cases of SSPE that were associated with the resurgence of measles and to calculate the risk of developing SSPE.

METHODS

Brain tissue samples obtained from 11 patients with a presumptive diagnosis of SSPE were tested for the presence of measles virus RNA. Measles virus genotypes were determined by reverse-transcription polymerase chain reaction (RT-PCR) and by analysis of the sequences of the PCR products. A search of the literature was conducted to identify reports of cases of SSPE in persons residing in the United States who had measles during 1989-1991.

RESULTS

The measles virus sequences derived from brain tissue samples obtained from 11 patients with SSPE confirmed the diagnosis of SSPE. For 5 of the 11 patients with SSPE who had samples tested by RT-PCR and for 7 patients with SSPE who were identified in published case reports, it was determined that the development of SSPE was associated with the measles resurgence that occurred in the United States during 1989-1991. The estimated risk of developing SSPE was 10-fold higher than the previous estimate reported for the United States in 1982.

CONCLUSIONS

Vaccination against measles prevents more cases of SSPE than was originally estimated.

Changing trend of SSPE over a period of ten years

Sub acute sclerosing pan-encephalitis (SSPE) is a slowly progressive inflammatory disorder of the central nervous system. A decline in frequency has been noticed in most of the developed countries, whereas it continues to be high in developing countries. Though a number of studies have been carried out, the exact trend of SSPE is still not clear. Hence the present study was carried out to analyze the trend of SSPE over the past ten years in and around Chandigarh. A total of 205 patients with clinical features suggestive of SSPE were enrolled for the study during Jan'92 to Dec. 2001. Measles specific antibodies were detected in blood and CSF by HAI method. 114 patients were found to be positive for measles specific HAI antibody with a male preponderance. The number of SSPE cases were found to be more during the period 1992-95 in comparison to the next 6 years (p < 0.05). The high incidence of SSPE in our country could be due to improper vaccine coverage, poor cold chain maintenance or circulation of atypical measles virus strain.

Antibodies to borna disease virus in subacute sclerosing panencephalitis

Mechanisms causing persistence and reactivation of measles virus in subacute sclerosing panencephalitis (SSPE) are unknown. Borna disease virus (BDV) frequently causes latent or persistent infection in the nervous system. We investigated a possible association of these viruses in SSPE. Although BDV seropositivity was similar in SSPE and control groups, SSPE patients with high antibodies to BDV had earlier and more rapid disease. The findings suggest that BDV might be involved in the course, but not in the etiopathogenesis, of SSPE.

The epidemiology of subacute sclerosing panencephalitis in England and Wales 1990-2002

AIM

To assess the impact of measles/mumps/rubella (MMR) vaccine on the epidemiology of subacute sclerosing panencephalitis (SSPE) in England and Wales.

METHODS

Cases of SSPE resident in England and Wales with onset between 1990 and 2002 were reviewed.

RESULTS

A total of 47 cases were identified, 31 male and 16 female. There was an average annual decline of 14% in SSPE onset over the period, consistent with the decline in notified measles over the last 20 years. A history of measles was present in 35 (median age 1.3 years), the most recent recorded date being 1994; the interval from measles to onset of SSPE ranged from 2.7 to 23.4 years. Four children with a history of receipt of a measles containing vaccine were reported not to have had measles; two of these cases had a brain biopsy, and nucleotide sequence data confirmed wild measles infection. Brain biopsy specimens from a further three cases with a history of measles, of whom two had also had a history of vaccination, showed wild-type strain.

CONCLUSION

The prevention of endemic circulation of measles virus in England and Wales through the high coverage achieved with MMR vaccine, together with the measles/rubella vaccination campaign of 1994, has resulted in the near elimination of SSPE. However, the recent decline in MMR vaccine coverage, with the associated increase in localised measles outbreaks and cases in young infants, is of concern. It underlines the importance of maintaining high vaccine coverage in order to protect indirectly those most vulnerable to SSPE, namely infants too young to be vaccinated.

Subacute Sclerosing Panencephalitis in Bulgaria (1978–2002)

The epidemiology of subacute sclerosing panencephalitis (SSPE) has changed substantially since the introduction of measles vaccine. We studied the incidence of SSPE in Bulgaria based on cases admitted to the Child Neurology Clinic, University Hospital of Neurology and Psychiatry, Sofia, for a 25-year period (1978-2002). The SSPE incidence prior to and during the period of routine measles immunization was analyzed. SSPE was diagnosed in 40 children (29 males and 11 females, mean age 8.5 years), 28 from 1978 to 1984 (average 4 patients/year), and 12 from 1995 to 2002 (average 1.7 patients/year). Thirty-eight cases (95%) were non-immunized and had early measles infection. Age at onset of SSPE ranged from 8 to 11 years (52.5%) with a mean latent period of 7 years following measles infection. The increase in SSPE incidence (1995-2002) following a 10-year disease-free period (1985-1994) appears to be related to early measles infection (mean age 11 months) during the measles epidemic of 1991-1992. During the period 1995-2002, children had earlier measles infection (average 11 months) and earlier onset of SSPE (mean age 8.4 years) than in the period 1978-1984 (mean age at measles infection 18 months, and of SSPE onset 11.2 years). The SSPE incidence in Bulgaria during the 25-year period from 1978 to 2002 confirms the importance of early measles infection as a risk factor for SSPE, and the role of routine measles immunization in SSPE prevention.

Subacute sclerosing panencephalitis in children: prevalence in South China

This investigation reports the prevalence and clinical profile of subacute sclerosing panencephalitis in two developed cities of southern China. A territory-wide survey was conducted to identify all subacute sclerosing panencephalitis cases diagnosed during 1988-2002 in Hong Kong and Macau. Altogether, 10 cases (male:female = 7:3) were identified of whom six were still alive. The prevalence rate of subacute sclerosing panencephalitis in Hong Kong and Macau in 2002 was 1 per million total population or 5.5 per million children. The mean age of presentation was 9.4 years (range = 4-14 years). Presenting features included myoclonus (60%), deterioration in school performance (30%), and transient visual impairment (10%). The clinical course was highly variable. Most had subacute course, but two deteriorated rapidly and died within 6 months. Seven children had measles infection, and the majority of infection (86%) occurred during the world measles epidemic in 1988. The mean interval between measles infection and onset of subacute sclerosing panencephalitis was 6.5 years (range = 3-11 years). There has been an increasing trend of subacute sclerosing panencephalitis in southern China after the measles outbreak in 1988. Active surveillance of subacute sclerosing panencephalitis for those with measles infection during the 1988 outbreak is necessary to conduct multicenter drug trials for this devastating disease.

Nasu-Hakola disease: a rare entity in Italy. Critical review of the literature

Nasu-Hakola disease (NHD, polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy, PLOSL) is a recessively inherited disorder characterized by systemic bone cysts and progressive presenile dementia associated with sclerosing encephalopathy. The disease has a worldwide distribution, but most patients have been reported in Finland and in Japan; in Italy there are anecdotal reports. The combination of neuropsychiatric symptoms and bone cysts is unique to this disease, which we believe to be underestimated in Italy. The molecular defect has been identified in loss-of-function mutations in the TYROBP gene in Finnish and in Japanese patients, and in the TREM2 gene in other families of different ethnic origins. We reviewed the international literature to define better the diagnostic steps and to draw the attention of neurologists and orthopaedic specialists to the disease. The identification of new cases followed by appropriate genetic counselling, genetic analysis, and study of the territorial distribution of affected patients could be a good strategy to follow in order to improve understanding of the disease.

Wild-type measles virus in brain tissue of children with subacute sclerosing panencephalitis, Argentina

We studied eight children who had measles at 6 to 10 months of age during the 1998 Argentine measles outbreak and in whom subacute sclerosing panencephalitis developed 4 years later. We report the genetic characterization of brain tissue–associated measles virus samples from three patients. Phylogenetic relationships clustered these viruses with the wild-type D6 genotype isolated during the 1998 outbreak. The children received measles vaccine; however, vaccinal strains were not found.

[Epidemiology of subacute sclerosing panencephalitis in Okinawa, Japan--the second report 1977-1999]

There were 16 cases (11 males and 5 females) of SSPE in Okinawa from 1977 to 1999. The incidence was 0.58 per million population per year for the last 23 years, being higher than in other reports in Japan. Six of the 16 cases contracted measles in 1990. The measles antibody of SSPE cases after 1989 became lower than previously.

Clinical and epidemiological characteristics of subacute sclerosing panencephalitis in Bulgaria during the past 25 years (1978-2002)

The aims of the present study are to establish the subacute sclerosing panencephalitis (SSPE) incidence in Bulgaria for the 25-year period 1978-2002; to analyze the SSPE incidence prior to, and in the period of, routine measles immunization; and, to analyze the clinical characteristics of SSPE. SSPE was diagnosed in a total of 40 children; 28 of were diagnosed between 1978 and 1984, and 12 between 1995 and 2002. Thirty-eight cases (95%) were non-immunized and have had an early measles infection (mean age 16 months). The SSPE onset occurred primarily between 8 and 11 years of age (52.5%) with a mean latent period of about 7 years after the measles infection. After the 10-year disease-free period (1985-1994), the SSPE incidence increased between 1995 and 2002 because of the 1991-1992 measles epidemic. During the period 1995-2002 children with earlier measles infection and earlier SSPE onset predominated, compared to the period 1978-1984. The initial clinical manifestations included intellectual deterioration in 35%, extrapyramidal hyperkinesias in 29%, epileptic seizures in 15%, hemiparesis in 10%, and visual disturbances in 10% of the cases. Nine children (22.5%) demonstrated an atypical onset. A rapidly progressive course was observed in 4 children (10%) and a chronic progressive course with pseudoremissions over 2 years-in 8 cases (20%). Our analysis of the SSPE incidence in Bulgaria for the 25-year period (1978-2002) supports the importance of early measles infection as a crucial risk factor for this persistent neuroinfection. Moreover, it confirms the role of routine measles immunization in SSPE prevention.

A continuing high incidence of subacute sclerosing panencephalitis (SSPE) in the Eastern Highlands of Papua New Guinea

The aims of this descriptive study were to confirm the high incidence of subacute sclerosing panencephalitis (SSPE) previously reported from Papua New Guinea (PNG) and to relate SSPE to previous measles vaccination and measles illness. From February 1997 to April 1999 we diagnosed a total of 55 patients with SSPE at Goroka Base General Hospital in Eastern Highlands Province (EHP) of PNG. The diagnosis was based on high cerebrospinal fluid and serum measles virus antibody titres with progressive neurological disorder and myoclonic jerks. Of these 55 patients 42 were from EHP, including 32 whose onset was in the 2-year period 1997-1998. The annual incidence of SSPE in EHP in these 2 years was 98 per million population under 20 years of age, the highest ever reported. This incidence was more than ten times higher than the highest incidence in the prevaccine era reported from elsewhere. The mean age of onset of SSPE was 7.7 years (range 2.8-14.8 years) and the interval between measles and the onset of SSPE, where known, had a mean of 5.9 years and a range of 2.5-11.1 years. Among the SSPE patients 19 had a documented history of measles vaccination. Eight of these 19 also had documentation of previous measles illness; of these, seven were vaccinated after the development of measles and one was vaccinated 20 days before measles illness. Two non-SSPE children received vaccination twice which was documented and subsequently developed measles which was also substantiated by documentation. Two patients with SSPE yielded amplified nucleotide sequences of measles virus that were different from any of the vaccine strains. We found no evidence to implicate measles vaccination in the development of SSPE.

Fulminating adult-onset subacute sclerosing panencephalitis in a 49-year-old man

CONTEXT

Subacute sclerosing panencephalitis (SSPE) is a rare, slow viral infection caused by a defective measles virus. It is characterized by progressive mental deterioration associated with motor impairment and prominent myoclonus. In about 10% of all cases, the disease can progress rapidly and lead to death within a few months. The oldest previously reported fulminating case was in a 25-year-old man.

OBJECTIVE

To emphasize the relationship between retinal involvement and acute SSPE by reporting the case of a 49-year-old man with clinical, laboratory, and pathological evidence of acute SSPE.

SETTING

Hôpital de l'Enfant-Jésus, Quebec, Quebec.

REPORT OF A CASE

This man was referred to the Department of Neurological Sciences on March 21, 2001, because of recent behavioral changes and progressive cognitive impairment over the past few months. Medical history was unremarkable except for an episode of measles in his childhood. Neurological examination showed bilateral myoclonic jerks. Ophthalmic examination revealed bilateral macular swelling and papilledema. Electroencephalography showed periodic sharp and slow-wave discharges. Magnetic resonance imaging showed bilateral diffuse T2-signal hyperintensities in both periventricular and subcortical white matter. Cerebrospinal fluid antimeasles antibody titers were highly positive. An Omaya reservoir was inserted and therapy using a combination of high-dose intrathecal interferon alfa and oral isoprinosine were administered for 6 weeks. Despite transient subjective improvement in the patient's condition, it continued to deteriorate, he became bedridden, and he died on June 26, 2001.

CONCLUSION

To our knowledge, this patient is the oldest case of SSPE reported in the literature. This patient and other patients with acute SSPE associated with bilateral macular swelling described in the literature raised the possibility of measles virus-acquired virulent neurotropism in the retina before invading the central nervous system.

[Epidemiologic features of subacute sclerosing panencephalitis from clinical data of patients receiving a public aid for treatment]

In 1999, clinical data of 125 patients with subacute sclerosing panencephalitis (SSPE) were obtained by the Research Committee from local prefectural governments. The data were made by physicians treating the patients, and were submitted to the governments when the patients applied for the aid. By analyzing the data, we observed the epidemiologic features of the disease in Japan, and discussed the availability of the data as the source of epidemiologic researches. Of the 125 patients, 66 were males and 59 were females. The distribution of age at onset had a peak in 5-14 years of age with the average of 10.3 years. Among the 109 cases in which the time of infection was obvious, more than 80% suffered from measles before 2 years of age, in agreement with the hypothesis that measles infection in young age is a risk factor of SSPE. The interval between measles and the onset of SSPE was between 5 and 10 years in most cases, with average of 8.8 years, median of 4.3 years, ranging from 2 months to 23.6 years. Because the data contain some problems, we have to observe the epidemiologic features of SSPE in Japan based on multiple data sources including this one, considering their advantages and disadvantages.

Adult-onset subacute sclerosing panencephalitis: clinico-pathological findings in 2 new cases

Subacute sclerosing panencephalitis (SSPE), an uncommon disease usually affecting children and adolescents, is caused by persistent measles infection that progresses to chronic infection with fatal outcome. The debut of this disease in adults is rare, with a small number of cases in the medical literature. This article presents the clinical, radiologic and post-mortem neuropathologic findings in 2 new cases of women with SSPE (1 of them during pregnancy), which showed very atypical clinical characteristics, presentation and evolution. The influence of pregnancy on the course of the disease was unfavorable, in keeping with earlier reports. Our patients showed a very prolonged biphasal clinical course, with a period of disease-free remission that lasted several years. Histological study disclosed features of inflammatory disease associated with others of a neurodegenerative nature, such as the formation of neurofibrillary tangles, which would relate SSPE with other tauopathies.

Quantitative evaluation of intranuclear inclusions in SSPE: correlation with disease duration

Three types of intranuclear inclusions in neurones, oligodendrocytes and astrocytes were quantitatively evaluated by electron microscopy in the autopsy material derived from six cases of subacute sclerosing panencephalitis (SSPE) with different duration of disease. Viral nucleocapsids were found in neurones and oligodendrocytes with the highest incidence (about 38% of nuclei) in two acute cases (adolescent), whereas in two subacute cases only 10% of nuclei of these cells contained nucleocapsids. However, in one acute case (child) and one chronic case, no nucleocapsids were detected at all, despite very intensive study. Two other types of intranuclear inclusions--nuclear bodies (NBs) and granulofilamentous inclusions (GFs) were present in astrocytic nuclei in all cases. Nuclear bodies were found the most frequently (about 66%) in cases of a several-week-long duration, and their incidence decreased with the extended duration of the disease. In the case of a seven-year-long duration, about 31% of nuclei contained NBs. The incidence of certain types of NBs varied also in individual groups of cases, and the same applied to the occurrence of cellular nuclei with different numbers of NBs. Nuclear bodies types IVand V occurred with similar frequency, regardless of the disease duration. The highest incidence of nucleocapsids and NBs was accompanied by the highest (about 25%) frequency of GF in astrocytic nuclei. The incidence of the latter declined with the prolonged duration of the disease, and in the chronic case it was about 16 times lower than in acute cases. In some acute and subacute cases, GF occurred together with NBs. Astrocytic nuclei with both types of inclusions occurred with a similar frequency (about 1.6-1.8%).

Subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a progressive neurological disorder of childhood and early adolescence. It is caused by persistent defective measles virus. Brain biopsies or postmortem histopathological examination show evidence of astrogliosis, neuronal loss, degeneration of dendrites, demyelination, neurofibrillary tangles, and infiltration of inflammatory cells. Patients usually have behavioral changes, myoclonus, dementia, visual disturbances, and pyramidal and extrapyramidal signs. The disease has a gradual progressive course leading to death within 1-3 years. The diagnosis is based upon characteristic clinical manifestations, the presence of characteristic periodic EEG discharges, and demonstration of raised antibody titre against measles in the plasma and cerebrospinal fluid. Treatment for SSPE is still undetermined. A combination of oral isoprinosine (Inosiplex) and intraventricular interferon alfa appears to be the best effective treatment. Patients responding to treatment need to receive it life long. Effective immunisation against measles is the only solution presently available to the problem of this dreaded disease.

Changing epidemiological features of subacute sclerosing panencephalitis

BACKGROUND

Subacute sclerosing panencephalitis (SSPE) is a chronic central nervous (CNS) system infection caused by measles virus. Because changing immunization practices affect the epidemiology of measles and consequently SSPE, we examined the epidemiological data of our SSPE registry.

MATERIALS AND METHODS

Age of onset, age at onset of measles, duration of Latent period and immunization status were examined in cases recorded at the SSPE Registry Center in Turkey between 1975 and 1999.

RESULTS

Age of onset diminished from 13 years before 1994 to 7.6 years after 1995; age at onset of measles declined from 29 months to 20 months and the Latent interval from 9.9 years to 5.9 years. Age at onset of measles and immunization status did not directly affect the duration of the Latent period.

CONCLUSION

Although its incidence has decreased in Turkey, SSPE has been seen at younger ages in recent years. This change cannot be attributed solely to younger age at onset of measles. Factors affecting the duration of the Latent period should be investigated further.

Subacute sclerosing panencephalitis--a Pakistan perspective

Subacute sclerosing panencephalitis (SSPE) remains a problem in areas of the world where measles virus is prevalent because of a lack of commitment to universal vaccination. We recently studied 89 cases compatible with a clinical diagnosis of SSPE and tested for antibody in serum or cerebrospinal fluid for measles virus. Eleven cases were confirmed to be SSPE on the basis of strongly supportive laboratory data.

[Subacute sclerosing panencephalitis (SSPE) in Poland in 1996-1999. Phase VII of epidemiologic studies]

In the seventh phase of epidemiological studies of SSPE data were gathered on patients who developed the disease in 1996-1999. In this time period the diagnosis was confirmed in only 10 cases (4 in 1996, 4 in 1997, 0 in 1998 and 2 in 1999). This is a significant reduction of incidence in relation to the preceding stages, in particular to the years 1993-1995 in which 49 new cases were still reported. This is not ruling out the possibility that at the beginning of the years 2,000 cases would be diagnosed in which the first symptoms developed several or more months earlier.

[Subacute sclerosing panencephalitis]

Subacute sclerosing panencephalitis is a slowly progressive neurodegenerative disorder occurring in childhood and adolescence and is characterised by dementia, ataxia, myoclonias and other neurological focal signs, with an invariably fatal outcome. The author reviews the subject, focussing on epidemiology, clinical features, measles virus behaviour, host immune reactions, measles prophylaxis and treatment proposals.

Subacute sclerosing panencephalitis. Clinical aspects and prognosis. The Brazilian registry

Subacute sclerosing panencephalitis (SSPE) is an inflammatory neurodegenerative disease related to the persistence of measles virus. Although its frequency is declining because of measles eradication, we still have some cases being diagnosed. With the aim to describe epidemiological aspects of SSPE in Brazil, we sent a protocol to Child Neurologists around the country, 48 patients were registered, 27 (56%) were from the southeast region, 34 (71%) were male and 35 (73%) white, 27 (56%) had measles, 9 (19%) had measles and were also immunized, 7 (14%) received only immunization, 1 patient had a probable neonatal form. Mean time between first symptoms and diagnosis was 12 months (22 started with myoclonus or tonic-clonic seizures, 7 (14%) with behavioral disturbances); 36 patients (75%) had EEG with pseudoperiodic complexes. Follow up performed in 28 (58%) patients showed: 12 died, 2 had complete remission and the others had variable neurological disability. Our data shows endemic regions in the country, a high incidence of post-immunization SSPE and a delay between first symptom and diagnosis.

The history of studies on subacute sclerosing panencephalitis in Poland

The main trends are described in the studies of subacute sclerosing panencephalitis conducted in Poland or abroad with participation of Polish scientists. The history of these studies began in the years 1957-1959 with the works of Wender and Osetowska and ends presently at the end of our century with extinction of SSPE as a result of consistently conducted obligatory vaccinations against measles. The studies of Polish authors involved the problems of clinical diagnosis using immunological, electrophysiological and neurological imaging methods. Neuropathological problems were also studied extensively. Parallely with similar studies in the foremost foreign centres trials of SSPE treatment were undertaken in Poland, in recent years by means of intracerebroventricular administration of interferons. An original Polish method was the treatment with inducers of endogenous interferons. After the introduction of vaccinations against measles epidemiological studies repeated in the whole country were introduced for the assessment of the results of this preventive measure. These studies are regarded as model ones at international level.

Case report and molecular analysis of subacute sclerosing panencephalitis in a South African Child

This is the first case of subacute sclerosing panencephalitis from South Africa in which the molecular characteristics of the causative measles virus were examined. The virus found is classified as genotype D3, which has not previously been found in Africa and was last circulating in the United States before 1992.

[Epidemiology of subacute sclerosing panencephalitis in Okinawa, Japan, 1970-1996]

In Okinawa, there were ten cases (7 male and 3 female) of subacute sclerosing panencephalitis (SSPE) from 1970 to 1996. All cases had a history of measles and none had received measles vaccination. The incidence of SSPE in Okinawa was 0.31 per million in 1970-1996. Being higher than other districts in Japan. Two cases contracted measles in 1973 and other three in 1990, showing a tendency to cluster.

Role of the Australian Paediatric Surveillance Unit in monitoring communicable diseases of childhood

The Australian Paediatric Surveillance Unit (APSU) conducts active national surveillance of conditions affecting children, including communicable diseases and their complications. By mailing over 900 clinicians each month the APSU gathers national information, not available from other sources, about the incidence, demographic and clinical features of these conditions. In some conditions APSU data supplements that available from existing schemes. The APSU has monitored 20 conditions to date. Eight of these are communicable diseases or their complications, two have a possible infectious aetiology and one frequently presents with infection. Since its inception in 1993 the return rate of monthly report cards by the mailing list has increased from 88 per cent to 94 per cent. Return rate of questionnaires for the communicable diseases studied ranged from 74 per cent to 100 per cent. Studies have enabled estimation of disease incidence, identification of risk factors and possible preventive strategies and provision of detailed clinical information. Although the APSU cannot serve a public health role by case identification and contact tracing it provides information that contributes to the communicable disease strategy for Australia.

Environmental risk factors for subacute sclerosing panencephalitis (SSPE)

In Israel, SSPE has been shown to be much more frequent among Sephardic Jews and Arabs than among Ashkenazic Jews. In the present study, we tried to explore environmental factors that may be of etiological importance and explain these differences in prevalence. The study is a case-control one, which includes 95 patients and 2 groups of controls, with 95 people in each. The general population controls were group-matched to the case group by sex, age, and ethnic origin. The family controls consisted of the sibling closest in age to each patient. A statistically significant positive correlation was found between risk of SSPE and early measles infection, large family, overcrowding in the home, older age of the mother, higher birth order, fewer years of schooling of the parents, fewer cultural activities, and rural place of birth. All these factors are interpreted as contributing to a higher risk of early measles infections, which thus may well be the main risk factor for SSPE.

[Subacute sclerosing panencephalitis (SSPE) in Poland in the years 1993-1995. The sixth stage of epidemiological research]

Data was collected about 49 newly diagnosed cases of SSPE in the years 1993-1995 in Poland. In the analyzed period of time a falling of tendency the incidence of SSPE was maintained. Overall incidence--0.42 per million population, was lower than the incidence in years 1990-1992, when it was 0.72. The tendency of a shift towards older age group was maintained--the peak incidence was observed among 19 year olds, as opposed to 15 year olds in the previous analyzed time period. The authors explain the dropping SSPE incidence in Poland with a drop in measales incidence, which is a consequence of growing measles vaccine coverage rates. The influence of a big measles epidemic which occurred in 1989-1990 on a potential rise in number of SSPE cases has not been noted, but further observations are needed.