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ActaDV ActaDV
Advances in dermatology and venereology Acta Dermato-Venereologica
Modified Measles: A Diagnostic Challenge
Jozefien ROOSE 1 #, Celine ROHAERT 1 #, Annelien JADOUL 1, 2, Regina FÖLSTER-HOLST 3 and Dirk VAN GYSEL 1 *
1
Department of Pediatrics, OLV Hospital Aalst, BE-9300 Aalst, 2 University of Louvain, Louvain, Belgium and 3 Department of Dermatology, University Medical Center Schleswig-Holstein, Campus Kiel, Germany. * E-mail: dirk. van. gysel @ olvz-aalst. be
#
These authors contributed equally to this manuscript. Accepted Oct 19, 2017; Epub ahead of print Oct 23, 2017
The incidence of measles has reduced since the availability of live attenuated vaccines. However, despite all the efforts made to eradicate measles, outbreaks still occur in Europe( 1 – 3). The persistence of measles can be explained by importation of the virus from other countries, vaccination refusal and, less frequently, primary vaccination failure. Furthermore, waning measlesspecific IgG titres after vaccination and lack of natural immunological boosting due to increasing vaccination rates lead to secondary vaccination failure. Thus, measles can occur even in fully vaccinated individuals when exposed to wild-type measles in an outbreak setting( 1, 4, 5). We report here a case of a 15-year-old boy who developed measles despite having had 2 previous doses of live attenuated measles-mumps-rubella( MMR) vaccine, administered at the ages recommended by the WHO( 6). The aim of this publication is to remind healthcare workers of the increasing occurrence of measles in previously vaccinated individuals, so called“ modified” or“ secondary” measles. Due to the possible life-threatening complications of measles, and in order to prevent further spread of the disease, healthcare workers should be familiar with the clinical course of( re)-infection and altered laboratory findings after vaccination( 7).
Fig. 1. Morbilliform rash in the neck on admittance to hospital( day 3 of the exanthem).
CASE REPORT
A 15-year-old boy was referred to the emergency department with high fever and a generalized rash. His symptoms had started 3 days earlier with a strong headache, general malaise, conjunctivitis and high fever( up to 39.9 ° C). On day 2 a rash appeared, starting on his face and spreading to his neck, upper and lower trunk and extremities. Approximately 10 days before the onset of symptoms, the patient had visited Wallonia, a part of Belgium recently affected by an outbreak of measles. The patient had been vaccinated twice for measles: at the age of 2 years and at the age of 10 years. He had no history of immunodeficiency or immunosuppression. His current medication consisted of methylphenidate hydrochloride( Equasym ®) 30 mg / day for ADHD.
Physical examination revealed that his general condition was impaired because of the symptoms mentioned above, with an erythematous, confluent, maculopapular rash( Fig. 1) over his entire body except for the palms, soles and head. His body temperature was 38 ° C 2 h after intake of paracetamol. Neurological examination revealed terminal nuchal rigidity. Kernig’ s and Brudzinski’ s tests were negative. No other abnormalities were observed on general physical examination.
Laboratory investigations documented a white blood cell count of 5,670 /µ l( normal range 4,000 – 10,000 /µ l) and a C-reactive protein( CRP) of 51.8 mg / l( normal < 5.0 mg / l). IgM and IgG titres for measles were 0 and > 300 U / l respectively. IgM titres for both rubella and Epstein- Barr virus( EBV) were negative, whereas IgG titres were positive. Lumbar puncture excluded meningitis. To differentiate from other infectious agents, a standard set of 20 PCRs was performed on a nasopharyngeal aspirate and was found to be negative. Because of the very suggestive clinical features and course a second measles-specific RNA-PCR analysis on a saliva sample was requested, and proved to be positive.
Because of the risk of secondary bacterial infection treatment with ceftriaxone 2 × 2 g IV was initiated. Over the next 3 days the patient underwent clinical improvement and his fever gradually diminished. The erythematous morbilliform exanthem started to fade on the trunk and turned into a purpuric rash on the legs. On day 3 of hospitalization, ceftriaxone was stopped as all blood cultures were sterile and the patient was discharged from the hospital in good general health apart from a mild headache and low-grade fever.
DISCUSSION
Modified measles often has a milder, less characteristic, clinical course compared with primary measles and
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2018 Acta Dermato-Venereologica. doi: 10.2340 / 00015555-2825 Acta Derm Venereol 2018; 98: 289 – 290