EC PAEDIATRICS EC PAEDIATRICS Case Report Case Report: Fatal Vaccine Strain Measles Infection in a Child

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Case Report
Case Report: Fatal Vaccine Strain Measles Infection in a Child
Roberto Calzada-Lang1, Adriana Yock-Corrales2*, Mónica Nuñez3 and Marcela Hernández-de Meserville1
1Infection Prevention and Control Disease Department, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, CCSS, San José, Costa Rica
2Emergency Department, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, CCSS, San José, Costa Rica
3Pathology Department, Hospital Nacional de Niños Dr. Carlos Sáenz Herrera”, CCSS, San José, Costa Rica
Citation: Adriana Yock-Corrales., et al. “Case Report: Fatal Vaccine Strain Measles Infection in a Child”. EC Paediatrics 9.8 (2020).
*Corresponding Author: Adriana Yock-Corrales, Emergency Department, Hospital Nacional de Niños “Dr. Carlos Sáenz Herrera”, CCSS,
San José, Costa Rica.
Received: May 27, 2020
Abstract
Measles outbreaks has become a popular topic due to anti-vaccination movements. Severe side effects after Mumps Measles Ru-
bella (MMR) vaccination is a rare event. This is a case report of a 15-month-old patient who presented to the emergency department
(ED) with a thirteen-day history of fever, maculopapular rash with hemorrhagic lesions and purpuric crusts; with previous MMR
vaccination 4-days before symptoms. After he was stabilized in the ED, he was admitted in the ICU where he died due to severe septic

Keywords: Measles; Vaccine Strain; Pediatrics
Introduction
Measles is a viral disease that is highly contagious and remains to be an important cause of death among young children in developing
countries of Africa and Asia [1]. The infection is characterized by fever, malaise, cough, coryza, and conjunctivitis, followed by exanthe-
matic maculopapular rash with hyperpigmented lesions [2]. Complications of this disease can vary from mild to severe, like pneumonia
(most common severe cause of death in this group), encephalitis, acute disseminated encephalomyelitis and Subacute sclerosing panen-
cephalitis [3].
Global measles death has decreased due to the introduction of immunization protocols in the late 1960`s [1], which is a topic that
would be discussed further. Side effects for measles vaccine has been described, but as a cause of death has not yet being reported in the
-
ary to a fatal disease.
Case Presentation
A 15-month-old patient presented to the emergency department at the National Children’s Hospital with a previous history of 4 days of
fever, painful left arm, swelling of 2 cm with erythema, and mild rash on the scalp. Two days later he was admitted to a rural hospital with
irritability, pharyngitis, maculopapular rash with hyperpigmented lesions throughout the body. He was discharged of this hospital with
an initial diagnosis of chickenpox and symptomatic treatment was recommended. One day after discharged, he was taken to the National

Citation: Adriana Yock-Corrales., et al. “Case Report: Fatal Vaccine Strain Measles Infection in a Child”. EC Paediatrics 9.8 (2020).
Case Report: Fatal Vaccine Strain Measles Infection in a Child
Children’s Hospital because of worsening symptoms characterized by distal cyanosis, hyporexia and irritability. Two weeks before admis-
sion, the patient received the MMR vaccine, and according to his mother the symptoms started 4 days after the vaccination.
In the Emergency department, the patient was irritable, without signs of dehydration, with tachycardia, temperature of 37.9°C and
90% of oxygen saturation. He had hyperemic pharynx with small ulcerated lesions in the tonsils and bilateral submandibular adenopa-
thies of approximately 1cm, maculopapular rash with generalized hemorrhagic lesions and purpuric crusts (Figure 1), distal cyanosis and
cold extremities. Lungs were clear on auscultation. He had normal heart sounds, and abdominal exploration was normal.
Figure 1: Maculopapular rash with generalized hemorrhagic lesions and purpuric crusts. Initial laboratory investigations reported
a CBC with 15.040 leukocytes/mm3 (67% PMN`s, 8% bands), hemoglobin 12.1 gr/dL, and platelets 16.000/mm3. Blood gases reported
a pH of 7.29, pCO2 of 46 mmHg, pO2 of 35 mmHg, lactate of 2.4 mmol/L, HCO3 of 22 mEq/L, BUN of 14.8 mg/dL, creatinine of 0.23 mg/
dL, and a CRP of 82.9 IU/L. AST at 302 and ALT at 148 with normal bilirubin levels. A lumbar puncture was done. CSF had 5 leukocytes/
mm3, 75 erythrocytes/mm3, glucose of 92 mg/dl, 29 mg/dL of proteins, with no bacteria and negative culture. Two blood cultures and
one urine culture drawn on admission were negative. Fluid from skin vesicles were sent to the laboratory for molecular studies and VZV
and Herpes 6 were reported.
          
tachycardia and cold extremities, therefore the septic shock protocol was started. He required intubation, mechanical ventilation and
inotropic support; then he was admitted to the ICU.


Citation: Adriana Yock-Corrales., et al. “Case Report: Fatal Vaccine Strain Measles Infection in a Child”. EC Paediatrics 9.8 (2020).
Case Report: Fatal Vaccine Strain Measles Infection in a Child
Figure 2: C right lung


In ICU, the patient required high doses of inotropic support, treatment with vancomycin, cefotaxime and acyclovir was started; and


Other studies that were done during his stay in ICU were viral serologies with Ebstein Barr Virus IgM, Measles IgM and Rubella IgM
that were positive, Immunoglobulins were within normal range, Ferritin levels that were 121,700 ng/ml and HIV test that was negative.
A hemophagocytic lymphohistiocytosis syndrome was diagnosed three days after admission in ICU, with multiorgan failure. He died
6 days after ICU admission. An autopsy was performed. The histopathologic pieces that were obtained and analyzed, demonstrated the
presence of Warthin-Finkeldey giant cells. This pattern was presented in almost all the histopathologic pieces including thymus gland,
lymphatic nodes and lungs (Figure 3).
Because of his aggressive presentation, the histopathologic pieces were sent to the CDC after his death. CDC performed a study with
immunostaining by using measles IHC essay. This study was immunoreactive in: thymus, adrenal gland, skin, gastrointestinal tract, and in
2 more lung samples; in this case for the vaccine strain measles virus (Figure 3).

Citation: Adriana Yock-Corrales., et al. “Case Report: Fatal Vaccine Strain Measles Infection in a Child”. EC Paediatrics 9.8 (2020).
Case Report: Fatal Vaccine Strain Measles Infection in a Child
Figure 3: Histopathologic images. Figure A. Warthin-Finkelday giant cells in Measles pneumonia.
Figure B. Warthin-Finkelday giant cells in Lymphatic Nodes. Figure C. Warthin-Finkelday giant cells in Thymus.
Discussion
Measles is a highly contagious viral infection that can cause serious complications for children’s and adults health. It is known that
following exposure of the virus, 90 percent of susceptible individuals will develop measles. Clinical manifestations are well described
with fever, malaise, cough, coryza, and conjunctivitis, followed by exanthematic maculopapular that usually is presented from head and
progressively to thorax, back, and extremities [2].
The diagnosis of measles should be considered in an unimmunized patient with clinically compatible symptoms and history of virus
exposure. The diagnosis of infection is usually based on at least one of the following: positive serologic test for serum measles IgM anti-

measles virus RNA by reverse transcription polymerase chain reaction (RT-PCR) [4].
Long time ago it was one of the most devastating infections due that caused millions of deaths each year, but fortunately in the 1960´s
  
the most preventable diseases around the globe.

Citation: Adriana Yock-Corrales., et al. “Case Report: Fatal Vaccine Strain Measles Infection in a Child”. EC Paediatrics 9.8 (2020).
Case Report: Fatal Vaccine Strain Measles Infection in a Child
Globally, it is estimated that there are 84% less cases worldwide according to WHO’s data that runs from the year 2000 to 2016
(550,100 deaths in 2000 to 89,780 in 2016). The World Health Organization recommends immunization for all susceptible children and
adults for whom measles vaccination is not contraindicated. Reaching all children with 2 doses of measles vaccine, either alone, or in a
measles-rubella (MR), measles-mumps-rubella (MMR), or measles-mumps-rubella-varicella (MMRV) combination. This should be the
standard for all national immunization protocols [1].
Measles outbreaks has become a popular topic recently due to anti-vaccination movements in different parts of the world. Despite

there’s an uprising tendency of vaccination hesitancy in the general population. This has led to an increasing in susceptible population
because of suboptimal immunization levels.
     -
cludes all types of measles vaccines (MR, MMR or MMRV), and its doses [6,7]. Adverse effects of vaccines have always been an aspect of
priority in research protocols. The measles vaccine continues to be a subject of interest in this aspect. Generally speaking, most of the AE
were local and mild such as: pain, swelling, redness, or abscess formation at the injection site. Some other AE that were relatively com-
monly reported as systemic side effects was fever and headache [8,9].
   -
scribed as more severe and rare are parotitis, thrombocytopenia and very rarely serious anaphylactic reactions [9].
Idiopathic Thrombocytopenic Purpura (ITP) is a very rare side effect that has been well demonstrated to have a relationship with the
measles vaccination (MMR). ITP can occur in 1 to 3 children every 100,000 vaccine doses; but its incidence is lower than what is observed
in regard to the progression of the natural disease. That is the reason why it cannot be considered as a limitation for the vaccine use [10].
Another adverse effect following immunization and that is also a rare event that even vaccine trials are unlikely to detect, is the anaphylac-
tic reactions [11]. Some of this reaction have been studied in patients with egg allergy. Most cases in which there is an allergic reaction to
egg, but not clinical manifestations of anaphylaxis, can be safely immunized without special concerns [11]. Also, some studies have tried to
show that patients may be at risk of developing other complicated side effects after vaccination such as encephalitis, but none had proved
to be related to measles vaccination [8].

  -
sive therapy (including biologic therapy), are the ones that are considered to have the MMR and varicella vaccines contraindicated and
can present severe adverse events Some serious AE described in this populations are measles inclusion body encephalitis (MIBE), pneu-
monitis, and death as a direct consequence of disseminated measles vaccine virus infection [13].
This case illustrates a very severe presentation of post immunization measles infection in a patient with suspected lymphocyte deple-
tion, reports of severe VAE in the literature are limited in Latin America and nonexistent in some countries. Severe VAE´s are infrequent in
immunocompetent hosts but immunocompromised patients can have post vaccination fatal infections like in this patient. Unfortunately,

Conclusion
As measles is a highly contagious infection where vaccination is extremely important, adverse events are rare. The importance of this
case is to increase the awareness of the possible adverse events of the vaccines in patients with immunological diseases and the early ap-
proach in order to avoid the mortality of these patients.

Citation: Adriana Yock-Corrales., et al. “Case Report: Fatal Vaccine Strain Measles Infection in a Child”. EC Paediatrics 9.8 (2020).
Case Report: Fatal Vaccine Strain Measles Infection in a Child
Financial Disclosure
None.


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Volume 9 Issue 8 August 2020
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