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is present or at onset of rash . Persons with preexisting antibody levels that would be clinically protective against disease (or would asymptomatically boost) after a lesser or “casual” exposure, may be mildly to moderately symptomatic upon prolonged exposure in close quarters, such as an examination room. The vaccination history of the 2 physicians and the high avidity antibody were consistent with designation of these cases as having a SIR. Furthermore, the symptoms reported were modified or nonclassic; they were less severe and/or of shorter duration than what is typically observed in a primary infection. In the absence of a known exposure to a measles case patient, the possibility of measles would likely not have been considered. Laboratory testing of serum samples from asymptomatic or mildly ill contacts of a measles case patient can detect an immunologic response to measles infection [3, 7]. As reported by Helfand et al , many persons who were exposed to a measles case patient on a 3-day bus trip had a detectable IgM response, regardless of having received previous vaccination or, for some, having a history of natural measles infection. In addition, the microneutralization titers measured from the exposed persons on the bus in which the measles case patient traveled were significantly higher than those obtained from persons who traveled on the second bus in the caravan. The clinical presentations of the exposed persons with detectable
Concomitant with high PRN titers in acute phase serum samples. a very strong reaction in the IgG enzyme immunoassay was observed. Intensified surveillance for rash illnesses in an outbreak setting has frequently presented dilemmas for outbreak control when vaccinated persons with modified illness are identified as suspected case patients. High levels of IgG can interfere with IgM assays because of insufficient removal of the IgG from the serum. the serum samples collected from the 2 physicians and the index case patients (and other case patients in the Pennsylvania outbreak) were tested using a plaque reduction neutralization (PRN) assay . Although detection of IgM is the recommended method for measles confirmation. at comparable intervals after rash (4–9 days). PRN titers from the 2 physicians (as well as from the father in the Pennsylvania outbreak) were 10–168 times higher. In addition to IgM testing and IgG avidity testing.antibodies and/or measles-neutralizing antibodies. The father of the 2 unvaccinated siblings in the Pennsylvania . did not meet the measles clinical case definition . it is an unreliable marker for measles infection in persons with an SIR. The magnitude of the titers obtained from the PRN test from acute-phase serum samples collected from the primary measles case patients (who were identified as having low avidity or having initial IgG-negative test results) did not exceed 10. In contrast. as well as to false-negative results .564 (Tables 1 and 2). however. compared with that obtained from the primary case patients (data not shown). reflecting a robust booster response. giving rise to false-positive results.
The ability to detect IgM among persons with an SIR following an exposure to measles will depend on the magnitude and kinetics of the individual immune response (current and previous). Only 1 of the students had a detectable IgM response. For example. Similarly. possibly attributable to the very high levels of IgG and/or relatively low levels of IgM . or conjunctivitis. and 3 replicates of the serum run in the same test were IgM indeterminate (data not shown). and the sensitivity of the assay . However. but neither of the students presented with cough. the timing of the serum sample collection. and the avidity was also . real-time RT-PCR testing may detect virus in persons with modified illness. Both of the students had some rash and fever. inconsistent results for IgM were obtained from serum samples obtained from the 2 physicians (Tables 1 and 2).287 and 217.812). because of the rapid boosting of IgG. However. 2 vaccinated college students (cases 6 and 7 in ) were identified in the course of follow-up investigations of contacts of an acutely ill measles case patient. coryza.outbreak (who had a history of having received 1 MMR vaccine dose in childhood) was confirmed as a measles case patient by IgM testing performed on serum samples collected 4 days after rash. the other case was confirmed by virus detection using RT-PCR . In addition. The PRN titers obtained from the students were very high (119. when clinical samples are collected in a timely manner. it may not be possible to demonstrate a 4-fold rise in titer among SIR cases. during a measles outbreak in 2007 . the IgM was weakly positive.
unpublished data). depending on the levels of preexisting antibody. This occurred during a measles outbreak in 2006. therefore. Modified measles infections may also resemble other rash illnesses. reflect a continuum of clinical illness. because serum from measles-infected persons can cause interference in rubella IgM assays. In addition. which is a situation that can be confusing. including rubella. No spread cases from the 2 students were identified. including the 1 sample with results that were negative for rubella IgG. Because the serum samples were negative for measles IgM (and the case patients had symptoms that were suggestive of rubella). and could not be ruled out by avidity testing (CDC. In addition to the level of preexisting antibody. the avidity index for 3 of the samples (1 sample was IgG negative) was either intermediate or high and. Although 3 of 4 serum samples sent to the CDC for confirmatory testing were weakly positive for rubella IgM.high. the intensity of exposure (ie. producing falsepositive results . the dose of virus received) is an important risk factor for breakthrough infection and one that could not be quantified in studies that retrospectively determine the protective titer . 2 of the case patients with viral samples available for testing had positive results when later tested for measles by real-time RT-PCR. consistent with a SIR (cases 2 and 3 in ). the samples were tested for rubella IgM. As suggested by Chen et al . when several persons with a mild rash illness were identified. immunity to measles may not be absolute but. was inconsistent with a current rubella infection.
He had traveled to his home country and was exposed to children who had measles. As pointed out by Helfand et al . In the . The determination of whether a vaccinated individual who is exposed to measles (who develops symptoms that are suggestive of measles) represents a case patient and therefore a potential source of infection for others often hinges on a laboratory test result as the deciding factor. although prior disease is difficult to document. Reliance on the absence of IgM to rule out a case may be unjustified under these circumstances. The avidity was high. unpublished data).000 (CDC. and the PRN titer was >160. because boosting from exposure to wild-type measles virus will be rare. Initially. including many patients who were unvaccinated. This may also occur among older persons who have a history of natural disease. the rate of nonclassic infection is likely to increase as measles control improves in a population.against symptomatic infection. the 2 physicians in this report did not infect any patients. However. One such case occurred in 2008 in a 55-year-old man who was born outside of the United States and who claimed to have had measles in childhood. the case was confirmed as measles by IgM detection and by an RT-PCR result positive for measles. the case was not strongly suspicious for measles because of the nonclassic presentation and disease progression. Despite ample opportunities for transmission of virus. The absence of circulating virus and the periodic boosting that may have provided additional protection from infection may alter the paradigm of lifelong (asymptomatic) immunity after vaccination or disease.
An investigation into the timing of the rise and fall of neutralization titers in previously vaccinated persons with modified measles is underway. is valuable for surveillance purposes in support of measles eradication efforts. Margaret Coleman. the limitations of standard methods for confirmation (ie. The collection of viral samples in addition to serum samples is strongly recommended.co. particularly a cough. should positive laboratory results trump the clinical case definition?). Although this report may raise questions regarding case classification for persons with a mild rash illness detected during a measles outbreak (eg. Gary Brook and Daniel McCrea *Corresponding author: Mahua T Chatterjee mahua142003@yahoo. more of these difficult cases will be confirmed by detection of measles RNA. however. The ability to discern measles infection in persons with an SIR. The absence of spread cases from the 2 physicians in this report suggests that there may be limited replication of virus in vaccinated persons with mild or short-lived symptoms. The absence or reduced severity of respiratory symptoms. Measles mimicking HIV seroconversion syndrome: a case report Mahua T Chatterjee*.future. Additional studies are needed to determine whether persons with modified measles can infect others. may result in lower infectivity relative to a classic measles infection [13.uk . 14]. IgM detection) in cases of modified or nonclassic measles may be better appreciated.
com/content/4/1/41 Received: Accepted: Published: 15 October 2008 6 February 2010 6 February 2010 © 2010 Chatterjee et al. As a highly infectious disease. and anti fungal cover. The characteristic rash appears several days after the onset of fever. but its clinical suspicion was low. which permits unrestricted use.jmedicalcasereports. Acton Lane. The rash is maculopapular and erythematous. coryza and conjunctivitis. the mortality rate . She became hypoxic within 24 hours of presentation and began to tire. Koplik's spots are rarely seen but are pathognomonic of disease.1186/1752-1947-4-41 The electronic version of this article is the complete one and can be found online at:http://www. and reproduction in any medium. Department of Medicine. Her respiratory symptoms were out of proportion to the findings of her chest radiograph. Case presentation A 28-year-old Polish woman presented ill to the accident and emergency department of a district general hospital. measles must be increasingly considered as a differential diagnosis in patients presenting with fever and rash. which remained virtually normal. In the developed world. Serological measles was confirmed as part of a viral screen. distribution. provided the original work is properly cited. Introduction Measles is a highly communicable acute disease that is caused by the airborne transmission of a paramyxovirus. identified patients must be isolated in the hospital setting. She was given cotrimoxazole. which spreads from the head to the torso and the extremities. has reduced the high mortality rate associated with measles in many countries . She was taken off all treatment and discharged home feeling well. please log on. London NW10 7NS. oral soreness.Author Affiliations Central Middlesex Hospital. Journal of Medical Case Reports 2010. Human immunodeficiency virus seroconversion syndrome complicated by Pneumocystis carinii pneumonia was high among the differential diagnoses.org/licenses/by/2.0). Abstract Introduction Measles is on the rise in the United Kingdom and must be considered in the differential diagnosis of any patient presenting with fever and rash. She had painful genital ulceration. Human immunodeficiency virus polymerase chain reaction came back as negative and her symptoms resolved within 10 days of presentation. With its incidence rising in the United Kingdom. as well as improved clinical care. Avery Jones Postgraduate Medical Centre. UK For all author emails. Vaccination against measles. together with improvements in the socio-economic conditions of the population. Conclusion The presentation of measles in this patient was unique and atypical. 4:41 doi:10. In its typical form it is characterized by high fever. and a facial rash. high-dose steroids. broad spectrum antibiotics. thus requiring noninvasive ventilation. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. cough. Park Royal. licensee BioMed Central Ltd. fever.
we sought an infectious disease opinion. This is largely attributable to the vaccination controversy regarding a potential link between the combined measles. Tests for viral screen (including measles IgM and IgG). abnormal liver function tests revealed an alanine transaminase (ALT) level of 342I U/L (NR = 0 to 55) and alkaline phosphatase (ALP) level of 185 IU/L (NR = 40 to 150). Within 20 hours of presentation she developed type 1 respiratory failure with a pO2 of 9. oral soreness and candidiasis. Antifungal topical treatment and appropriate antibiotic therapy for a concurrent urinary tract infection provided minimal relief. was initially treated with intravenous acyclovir and highdose prednisolone. meanwhile. non-productive cough. With the reappearance of measles in the United Kingdom among the unvaccinated population. and a facial rash. she developed severe burning and itching of her genital region. HIV. She had no relevant drug history or sexual history. vaccination coverage rates in many European countries have never reached the target >90% of the population . measles can present atypically. and noninfective causes such as Bechet's. As with most diagnostic challenges in medicine. complement levels. and 300 deaths per 1000 cases in immunocompromised patients. PCR. . Case presentation A 28-year-old Polish woman who has been residing in the United Kingdom for four years presented to the accident and emergency department of a district general hospital with severe ulceration of the perineal area. Meanwhile. or in patients where the vaccine has failed to work. She had crepitations at the base of her left lung.from measles among the immunocompetent remains low which is estimated at 1 per 1000 cases. it must be increasingly thought of as a differential diagnosis in any patient presenting with a fever and maculopapular rash. although clinically she began to develop bronchial breathing at her left lung base.26 × 109/L (NR = 1. and initial oxygen saturations of 100% on air. blood pressure of 105/60. tenderness on palpation at the right upper quadrant of her abdomen. see Figure 1). Her illness started two weeks prior to presentation with a flu-like illness and sore throat for which she was prescribed with antibiotics. vomiting. The differential diagnosis at this stage included human immunodeficiency virus (HIV). She had mild injection of both eyes. autoimmune screen. On examination our patient was unwell with a temperature of 38°C. There was some erythema at the back of her mouth and a white coating resembling candida. This leads to concerns that endemic measles may reemerge.10 to 4. She began to tire and required noninvasive ventilation. mumps and rubella (MMR) vaccine and autism. Here we present an unusual case of measles which was initially identified as human immunodeficiency virus (HIV) seroconversion syndrome. herpes simplex virus. and an ill-defined rash over her face and neck. The associated pain was so severe it prevented her from moving her legs freely.80) and a C-reactive protein (CRP) level of 49 (NR = <5). fever. dysuria. The most marked findings were of vulval and perineal erythema and excoriations with discrete ulceration. Similarly. the incidence of measles is rising in the United Kingdom and in Europe . This rises to 100 per 1000 deaths in developing countries. Her respiratory symptoms were out of proportion to the changes exhibited in her chest X-ray (minimal consolidation at her left lung base. heart rate of 110 beats per minute. Our patient.5 KPa on 10 liters of oxygen. and systemic vasculitis. and a facial rash. and immunoglobulin levels were requested. systemic lupus erythematosus. and rash. soreness of the mouth. However. With these initial findings of genital ulceration. fever. anti-streptolysin O (ASO) titre. Her medical history included von Willibrand's disease and a caesarean section two years prior to presentation. Three days into the illness. Reiter's syndrome was also considered as it can present without arthritis in women. Further investigations revealed that she had a lymphopenia of 0. She further developed high fever.
were stopped. Her symptoms had completely resolved by day 10 of admission. to refute such a link . her blood tests revealed negative HIV PCR. A careful immunization history should be included in the medical clerking. Her steroid medication was slowly weaned and the antibiotics. however. which may then lead to a replication in the urinary tract . . A single dose vaccine schedule. The main presenting complaint in this case was genital ulceration and severe perineal pain.1 Kpa. It seemed likely that she had an atypical viral infection. The patient we discussed in this case report had received one dose of the measles vaccine in Poland when she was a baby. Elevated serum titres of IgM and IgG antibodies to measles were subsequently demonstrated. for example. measles was declared eliminated in 2000. Localized outbreaks are often initiated by an imported case from Europe or elsewhere. Her steroids were also changed to high-dose methylprednisolone. In 2005. allows the gradual accumulation of a cohort of susceptible people. Severe hypoxia requiring noninvasive ventilation is not explained by this relatively normal chest X-ray. Discussion Measles meets the criteria for diseases that can be eradicated and yet remains endemic worldwide. however. thus confirming a diagnosis of acute measles. the incidence of this disease is rising with localized outbreaks in unvaccinated children and adults. This case illustrates the diagnostic difficulties of atypically presenting measles and emphasizes that the disease course can be moderately severe in adults. This case was responsible for the largest recent outbreak of measles in the United States . Nevertheless. Their location was unusual as they are more commonly found on the buccal mucosa. it must be considered increasingly as a differential diagnosis in any patient presenting with a fever and a maculopapular rash. In the United Kingdom. even with a coverage of 100% of the population. Most of these deaths occur in Africa and in Southeast Asia. However. normal immunoglobulin levels. There was no record of a second dose being given and she had never since been tested for serological evidence of immunity. including cotrimoxazole. and negative autoimmune screen. There is now much evidence. Interestingly. With the rising incidence of measles. Koplik's spots have less commonly been reported 2 to 3 days after the onset of rashes. The patient is now well. This is largely attributable to low vaccine uptake rates surrounding a controversy over the safety of the vaccine in the late 1990s. On day 4 of admission her facial rash had resolved and her oxygenation began to improve (PO2 13. while a second dose confers immunity to 99% of those vaccinated . there have been no reported cases in the literature of measles causing genital ulceration. negative ASO titre. In the United States. Another possibility was of an atypical but severe bacterial infection. vaccination failure has also been recorded . measles associated death remains low: 2006 saw the first measles death since 1992. The most likely diagnosis at this stage was HIV seroconversion complicated by Pnemocystis cariniipneumonia. Koplik's spots also normally appear in the prodromal period of illness and disappear before the onset of the measles rash. to the best of our knowledge. A vaccination history of our patient revealed that she had completed all her childhood vaccines in Poland. She was treated with intravenous broad spectrum antibiotics (imipenem and teicoplanin) and treatment doses of cotrimoxazole.Figure 1. The World Health Organization estimates that measles causes 454. it is more likely that this was pathognomonic Koplik's spots. This could explain the symptoms of dysuria. While the oral soreness and white coating at the back of our patient's mouth resembled candida. However.000 deaths annually. Meanwhile. an unvaccinated 17-year-old girl returning from Romania was found to be incubating the disease. Fio2 at 40%). normal complement levels. the measles virus infects epithelial cells of the host after airborne transmission.
made HIV serconversion with concurrent PCP high on our differential list. it must be increasingly considered as a differential diagnosis in patients presenting with fever and rash. The diagnosis of measles was picked up as part of a viral screening test although its clinical suspicion was low. Conclusion This case illustrates that measles can present atypically and that it can be a severe illness in young adults. of which four required hospitalization. In 2006. In retrospect. This focused our differential more toward diseases that involves primarily the mucous membranes. Pneumonia accounts for 56% to 86% of all measles associated deaths . Consent . Measles is highly infectious and clinical suspicion must remain high especially in a hospital setting because these cases need isolating. The severe genital ulceration and oral soreness was a unique presentation of the disease. This. measles associated death rates are highest below the age of 1 year and lowest between the ages of 1 to 9 years. This case highlights that measles can be of severe presentation in the young adult. maculopapular rash. and Koplik's spots. With the incidence of measles rising in the United Kingdom. the pointers to measles in this case were flu-like prodrome. injection of the eyes. While complication and mortality rates increase in adulthood. together with the mucosal findings and non-specific prodrome. Screening of healthcare professionals at the time of the outbreak showed that 3% of hospital staff members were not immune to measles. this district general hospital had seven healthcare professionals with positive serology for measles .Our patient's level of hypoxia was highly unproportional to the minimal consolidation seen on her chest radiograph. This case emphasizes the importance of considering measles as a differential diagnosis in any patient presenting with rash and fever. The severe hypoxia and bronchial breathing in the context of a normal chest X-ray was likely to be measles associated pneumonitis or as a result of superimposed infection with bacteria or other viruses.
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