Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Atypical Measles after Vaccination with Killed Vaccine Tore Rød, Kari Wold Haug & Jan C. Ulstrup To cite this article: Tore Rød, Kari Wold Haug & Jan C. Ulstrup (1970) Atypical Measles after Vaccination with Killed Vaccine, Scandinavian Journal of Infectious Diseases, 2:3, 161-165 To link to this article: http://dx.doi.org/10.3109/inf.1970.2.issue-3.02
Published online: 02 Jan 2015.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Deakin University Library]
Date: 07 November 2015, At: 18:29
Scand J Infect Dis 2: 161-165, 1970
ATYPICAL MEASLES AFTER VACCINAnON WITH KILLED VACCINE Tore Rl£Sd, Kari Wold Haug and Jan C. Ulstrup
Downloaded by [Deakin University Library] at 18:29 07 November 2015
From the Bacteriological/Virological Laboratory and the Pediatric Department, Ulleval Hospital, Oslo, Norway
ABSTRACT. Two cases are presented with diseases considered to be atypical measles as described by Fulginiti and Kempe. Two siblings, 8 and 9 years old, received measles vaccine in 1963 according to a schedule of 2 injections of killed vaccine 1 month apart followed by 1 injection of live vaccine. In 1967 they contracted natural measles infection and developed a serious illness with high fever, exanthem, pneumonia and prostration. The patients recovered within 2 weeks. One patient has persistent infiltration in his left lung as revealed by X-ray examination. The diagnoses were substantiated epidemiologically and confirmed serologically.
Individuals infected with measles virus after vaccination with inactivated measles vaccine (killed vaccine (K» may develop a disease which has been called "atypical measles" (5, 19). The disease is due to an altered immunological reactivity because of the previous contact with K. The disease is characterized by high fever, prostration, headache, myalgia, and diffuse pneumonitis with pleural involvement. Exanthem may be absent or uncharacteristic both with respect to elementary lesions and its distribution. The exanthem generally starts peripherally with redness and frequently oedema and progresses centripetally. Maculopapules, petechiae, vesicles and urticaria are seen. Atypical measles has been reported 1-5 years after the vaccination (5, 16, 17, 19), at a time when the hemagglutination-inhibition (HI) antibodies have been low or unmeasurable (5). The diagnosis of measles infection has been confirmed serologically. A changed immunological reactivity has also been revealed in the skin of K-vaccinated individuals upon injection with live measles vaccine (L) (4, 10, 15). The person may have an intense and early erythema, sometimes blisters, and later on induration. Corresponding reactions have not
been seen when L is used in a child who has had natural measles previously. A certain minimal amount of antigenic material of at least 2 injections with K seems necessary for the altered reaction to develop. Probably, this means that a secondary response must have developed. The conditioning vaccination schemes have usually been 3 injections of K at 1 month interval (KKK), sometimes with a booster of K 1 year after KKK. A combination of KK (2 injections with killed vaccine) followed by I injection of L after a month interval has also been used. The combination has had no immediate effects but has not prevented the paradoxical reactions later. We report here 2 cases of illness considered to be atypical measles which occurred in siblings, a boy and a girl. They had the same history of vaccination (KKL), were exposed at about the same time, and both presented a clinical picture as described (5). In the boy a pulmonary lesion has persisted for more than 1 1/ 2 year after the infection. The girl was the first to fall ill and the nature of her illness was not realized initially but measles infection was suspected when the brother was admitted for a similar disease 2 weeks later. The diagnosis was confirmed about 1 year later during a serological survey on stored serum pairs. Then new specimens were taken and all sera reinvestigated simultaneously. Both siblings had been vaccinated in 1963 when the family lived in New York State. CASE REPORTS Case 1 LiW, a girl born Nov. 11, 1959. Previous illnesses. Mumps in 1963, chickenpox in 1964 and infectious mononucleosis (probably) in 1966. Otitis Scand J Inject Dis 2
162
T . R¢d et al. Reexaminat ion No v. 7 revealed a good cond ition . Th e ESR was 15 mm. Serology. Complement fixation (CF) tests show ed no rise in titres to influ enza A and B, herp es simplex, mumps, varic ella, adeno- and respiratory sync ytial viru ses. PaulBunnell, My coplasma pneumoniae CF and cold agglut ination te sts were negative. CF antib odies to me asles virus were: Date of bleeding Oct . 10,1967 Me asles CF titre 8
Nov. 7,1967 512
D ec. 28, 1968 64
Case 2
Downloaded by [Deakin University Library] at 18:29 07 November 2015
a
Fig. J. LiW , Oct. 25, 1967. Bilateral pulmonary infiltration. Pleural effusion on the left side.
media with myringotomies 6 tim es and frequent throat infections. Present illness. Th e girl was h ospit alized Oc t. 22, 1967, because of suspicion of meningitis after 2 days with fever, nausea and vomiting, headache, drow siness and irritabilit y. She had no catarrhal symptoms. On admission. Th e girl was alert with slight back and neck stiff ness as the only clinic al signs of meningitis. Th e temperature was 40.6°C, th e pul se rate 120, BP 110/55 , Hb 12.5 g/100 ml, WBC 7800, ESR 65 mm /l hour. The spina l fluid showed 7 cells and 20 mg /loo ml of protein. X-ray of th e lungs showed a diffu se density extending over nearly th e entire left lung. On th e right side a perihil ar thickening was found . Ph ysical examinat ion of th e lungs revealed normal findings. The next day bronchial respiration was noted subscapularly on the left side, increasing th e following days. Th e fever continued and the pati ent was prostrated and vomiting. Blood cultures were negative. Penicillin-sensitive St aph ylococcus aureus were demonstrated f rom the nose but penicillin treatment was ineffective. On suspicion of Mycoplasma pneumonia tetracyclines were then given without effect. Another pulmonary X-r ay was carried out Oct . 25; infiltration of th e left upper as well as lower lobe was still dem onstrable and diffu se infiltration in th e right upper lobe (Fig. 1). WBC count was 6600, ESR 47 mm. On the 7th day of illness a fine maculopapular exanthem appeared on the lower abd omen and in the groi ns. Scarlet fever was suspected as the tongue this tim e showed a white fur and protruding papillae. A sh ift to chloramphenicol was dec ided mainly because of the persisting pulmonary findings. Later th e same day the temperature fell lyrically and subsequently she was afebrile with marked improvement in her condition. X-ray examination on Oct. 31 showed marked clearing of the lungs and no exudate (Fig . 2), and the patient was discharged on Nov. 3.
Scand J In fect Dis 2
LaW , boy born June 9, 1958, brother of patient 1. Previous illnesses. Mumps in 1963, chickenpox in 1964. Present illness. The boy was hospitalized on Nov. 6, 1967, after 3 days with high fever, incre asing somnolence and h allucin ations, photophobia, thoracic pa ins and dry cough. In itially he was treated by the famil y physician with tetracycline s. On admission to the Pediatric Department me asles was suspected and the patient was immediately tr ansf erred to the Department of Infectious Diseases and subjected to its routine of investigation.' On admission . The boy was somnolent and prostr ated but adequately answering questions. Bilateral conjunctival injection and redness of the tongue were seen. The temperature was 39.4°C, the pulse rate 120, and the BP 115/ 60. Crepitant ral es were auscultated over both lungs . A fine maculopapular exanthem appeared round the distal part of the legs as well as on both ankles and on dorsum pedis. Solit ary maculopapules and vesicles were found on the trunk . N o Kopli k's spots were seen but measles was suspec ted. Hb was 12.7 g/100 ml, WBC 6300 (lyrnpho, We th ank Professor H . Laake, M.D., for kind permission to publi sh the case.
",
F ig. 2. LiW , Oct. 31, 1967. Regression of find ings on previous X-ray.
Downloaded by [Deakin University Library] at 18:29 07 November 2015
A typical measles after vaccination with killed vaccine
163
cytes 12, monocytes 2, granulocytes with rod-shaped nuclei 6 and segmented 60%), ESR 55 mrn. X-rayon admission showed a density in the middle of the left lung, and a smaller density medially in the lower part of the right lung (Fig. 3). Tuberculin tests on Nov. 8, 1967, and on Jan. 11 and 18, and on May 10, 1968, were all negative. The patient had fever the first 3 days in hospital. The condition improved gradually and the boy was discharged Nov. 14. X-ray of the lungs Nov. 13 and Nov. 21, 1967, Jan. 3, 1968, and March 3, 1969, all showed persistence of pulmonary lesions described as either pleural thickening interlobarly or pulmonary infiltration (Figs. 4-6). On Nov. 21, 1967, the ESR was 15 mm, the patient had moderate cough and felt healthy. Serology. Cold agglutination and CF with a lymphogranuloma antigen (Lygranum) were negative. CF antibodies to measles virus were: Date of bleeding Measles CF titre
Nov. 6, 1967 32
Dec. 28, 1968 128
Epidemiology An epidemic of measles was going on in the Oslo area when the siblings contracted their disease. Playmates of both the girl as well as the boy became ill with typical measles one day after our patients. The boy may possibly have been infected from his sister.
DISCUSSION
Fig. 4. LaW, Nov. 13, 1967. Infiltration more distinct. Some interlobar fluid.
patients must be characterized as severe with prostration, pneumonia with pleural effusion and high fever. Both had atypical and abortive exanthems and the boy has furthermore persistent pulmonary changes as documented by X-ray investigation for more than 1 1/ 2 year after the
The clinical picture presented by the two siblings fits well with that described by Fulginiti et al. (5). The diagnosis is serologically proved for the girl and is also very likely for the boy and substantiated epidemiologically. The disease in both
Fig. 3. LaW, Nov. 6, 1967. Left-sided pulmonary infiltration on day of admittance. (Picture taken in bed.)
Fig. 5. LaW, Nov. 21, 1967. On lateral view it can be seen that the infiltration is localized to the anterior segment of the left upper lobe. The infiltration seems to be still more circumscribed and there is less interlobar fluid.
Scand J Infect Dis 2
Downloaded by [Deakin University Library] at 18:29 07 November 2015
164
1'. R¢!d et al. organisms in connection with later appearance of the corresponding infection. It has been reported with respiratory syncytial virus (3, 6, 12, 13, 18), trachoma (9), and Mycoplasma pneumoniae (20). The reactions are certainly of immunological nature because of their specificity, but the exact mechanisms involved are not known. Hypersensitivity reactions in connection with low humoral antibody levels have been blamed (7, 11). Others have stressed that circulating antibodies may develop earlier upon infection in prior recipients of inactivated vaccine (2). Virus and antibody may thus be present in the lung at the same time creating an unusual situation with development of pneumonia not seen in natural infection. The accelerated antibody response might even prevent or modify the rash. Finally, misrepresentation of the right antigens in the killed vaccine may be involved (8). Absence of IgA antibodies in the respiratory tract (1) may also be a contributing factor. The paradoxical reactions have never been reported after the use of live vaccines .
Fig. 6. LaW, Jan. 3, 1968. Persistence of the infiltration.
REFERENCES acute illness. Tuberculin tests and th e course of the illness exclude tuberculosis. The frequency of the atypical illness in Kvaccinated children exposed to natural measles has been reported to be quite high. Rauh and Schmidt (19) reported 8 cases of atypical measles among 125 exposed about 2 years after KKK, and 1 case among 9 exposed after KKK-K, the last injection given as a booster 1 year after the others. Fulginiti et al. (5) suspected that the reported cases represent a fraction of the total number that occurred because of the difficulty in diagnosing the illness as measles. The disease usually defies diagnosis unless suspected and appropriate virologic tests are performed. Our patients, born 1958 and 1959 and given KKL in 1963, were probably exposed at 2 weeks interval in 1967, and both contracted atypical measles. There has been no other reports from Norway of similar reactions probably because K has not been used. A few cases have been reported from Sweden (14, 17) in connection with trials with killed vaccine. Atypical reactions have also been seen after immunization with killed vaccines of other microScand J Infect Dis 2
1. Bellanti , J. A , Sanga, R. L., Klutinis, B., Brandt, B. & Artenstein, M . S.: Antibody responses in serum and nasal secretions of children immunized with inactivated and attenuated measles virus vaccines . New Eng J Med 280: 628, 1969. 2. Chanock , R. M., Parrot, R. H ., Kapikian, A. Z., Kin, H. W. & Brandt, C. D.: Possible role of immunological factors in pathogenesis of RS virus lower respiratory tract disease. In: Virus-induced immunopathology. Perspectives of virology VI, p. 125 (ed, M. Pollard). Academic Press, London and New York 1968. 3. Chin, J ., Magoffin, R. L., Shearer, L. A, Schieble, J. H . & Lennette, E. H.: Field evaluation of a respiratory syncytial virus and a trivalent parainfluenza virus vaccine in a pediatric population. Amer J Epidem 99: 449, 1969. 4. Fulginiti, V. A., Arthur, J., Perlman, D. S. & Kempe , C. H.: Serious local reactions following live measles immunization in previously killed-vaccine recipients. J Pediat 69: 891, 1966. 5. Fulginiti, V. A , Eller, J. J., Downie, A W. & Kempe, C. H.: Altered reactivity to measles virus. JAMA 202: 1075, 1967. 6. Fulginiti, V. A, Eller, J. J., Sieber, O. F ., Joyner, J. W., Minamitani, M. & Meiklejohn, G .: Respiratory virus immunization. 1. A field trial of two inactivated respiratory virus vaccines: an aqueous trivalent parainfluenza virus and an alum-precipitated respiratory syncytial virus vaccine. Amer J Epidem 99: 435, 1969.
Downloaded by [Deakin University Library] at 18:29 07 November 2015
Atypical measles after vaccination with killed vaccine 7. Fulginiti, V. A. & Arthur, J. H.: Altered reactivity to measles virus. Skin reactivity and antibody response to measles antigens in recipients of killed measles vaccine. J Pediat 75: 609, 1969. 8. Gard, S.: Vaccination mot massling (I): Satsa pa utveckling av inaktiverat vaccin. Lakartidn 65: 4897, 1968. 9. Grayston, J. T., Woolridge, R L. & Wang, S.: Trachoma vaccine studies in Taiwan. Ann NY Acad Sci 98: 352, 1962. 10. Harris, M. J.: Reactions to live measles vaccine in children previously given killed measles vaccine. Med J Aust 2: 989, 1967. II. Isacson, P.: Delayed dermal hypersensitivity after viral immunization. In: Virus-induced immunopathology. Perspectives of virology VI, p. 141 (ed. M. Pollard). Academic Press, London and New York 1968. 12. Kapikian, A. Z., Mitchell, R. H., Chanock, R. M., Shvedoff, R. A. & Stewart, C. E.: An epidemiologic study of altered clinical reactivity to respiratory syncytial (RS) virus infection in children previously vaccinated with an inactivated RS virus vaccine. Amer J Epidem 99: 405, 1969. 13. Kim, H. W., Canchola, J. G., Brandt, C. D., Pyles, G., Chanock, R M., Jensen, K. & Parrot, R. H.: Respiratory syncytial virus disease in infants despite prior administration of antigenic inactivated vaccine. Amer J Epidem 99: 422, 1969. 14. Lundback, H.: Vaccination mot massling (2): Levande vaccin att foredra. Lakartidn 65: 4905, 1968.
165
15. McNair Scott, T. F. & Bonanno, D. E.: Reactions to live-measles-virus vaccine in children previously inoculated with killed-virus vaccine. New Eng J Med 277: 248, 1967. 16. Nader, P. R, Horwitz, M. S. & Rousseau, J.: Atypical exanthem following exposure to natural measles: Eleven cases in children previously inoculated with killed vaccine. J Pediat 22: 22, 1968. 17. Norrby, E., Lagercrantz, R & Gard, S.: Measles vaccination VI. Serological and clinical follow-up analysis 18 months after a booster injection. Acta Paediat Scand 55: 457, 1966. 18. Parrot, R. H., Kin, H. W., Arrobio, J. 0., Canchola, J. G., Brandt, C. D., deMeie, J. L., Jensen, K. E. & Chanock, R. M.: Experience with inactivated respiratory syncytial and parainfluenza virus vaccines in infants. In: Vaccines against viral and rickettsial diseases of man. Scientific Publication No. 147, p. 35 (ed. A. Horwitz). Pan American Health Organization, Washington D.C. 1967. 19. Rauh, L. W. & Schmidt, R: Measles immunization with killed virus vaccine. Amer J Dis Child 109: 232, 1965. 20. Smith, C. B., Friedewald, W. T. & Chanock, R. M.: Inactivated Mycoplasma pneumoniae vaccine, evaluation in volunteers. JAMA 199: 353, 1967. T. R¢d, M.D., Medical Department, Sentralsykehuset i Akershus, 1474 Nordbyhagen, Norway
Scand J Infect Dis 1
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Atypical Measles after Vaccination with Killed Vaccine Tore Rød, Kari Wold Haug & Jan C. Ulstrup To cite this article: Tore Rød, Kari Wold Haug & Jan C. Ulstrup (1970) Atypical Measles after Vaccination with Killed Vaccine, Scandinavian Journal of Infectious Diseases, 2:3, 161-165 To link to this article: http://dx.doi.org/10.3109/inf.1970.2.issue-3.02
Published online: 02 Jan 2015.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [Deakin University Library]
Date: 07 November 2015, At: 18:29
Scand J Infect Dis 2: 161-165, 1970
ATYPICAL MEASLES AFTER VACCINAnON WITH KILLED VACCINE Tore Rl£Sd, Kari Wold Haug and Jan C. Ulstrup
Downloaded by [Deakin University Library] at 18:29 07 November 2015
From the Bacteriological/Virological Laboratory and the Pediatric Department, Ulleval Hospital, Oslo, Norway
ABSTRACT. Two cases are presented with diseases considered to be atypical measles as described by Fulginiti and Kempe. Two siblings, 8 and 9 years old, received measles vaccine in 1963 according to a schedule of 2 injections of killed vaccine 1 month apart followed by 1 injection of live vaccine. In 1967 they contracted natural measles infection and developed a serious illness with high fever, exanthem, pneumonia and prostration. The patients recovered within 2 weeks. One patient has persistent infiltration in his left lung as revealed by X-ray examination. The diagnoses were substantiated epidemiologically and confirmed serologically.
Individuals infected with measles virus after vaccination with inactivated measles vaccine (killed vaccine (K» may develop a disease which has been called "atypical measles" (5, 19). The disease is due to an altered immunological reactivity because of the previous contact with K. The disease is characterized by high fever, prostration, headache, myalgia, and diffuse pneumonitis with pleural involvement. Exanthem may be absent or uncharacteristic both with respect to elementary lesions and its distribution. The exanthem generally starts peripherally with redness and frequently oedema and progresses centripetally. Maculopapules, petechiae, vesicles and urticaria are seen. Atypical measles has been reported 1-5 years after the vaccination (5, 16, 17, 19), at a time when the hemagglutination-inhibition (HI) antibodies have been low or unmeasurable (5). The diagnosis of measles infection has been confirmed serologically. A changed immunological reactivity has also been revealed in the skin of K-vaccinated individuals upon injection with live measles vaccine (L) (4, 10, 15). The person may have an intense and early erythema, sometimes blisters, and later on induration. Corresponding reactions have not
been seen when L is used in a child who has had natural measles previously. A certain minimal amount of antigenic material of at least 2 injections with K seems necessary for the altered reaction to develop. Probably, this means that a secondary response must have developed. The conditioning vaccination schemes have usually been 3 injections of K at 1 month interval (KKK), sometimes with a booster of K 1 year after KKK. A combination of KK (2 injections with killed vaccine) followed by I injection of L after a month interval has also been used. The combination has had no immediate effects but has not prevented the paradoxical reactions later. We report here 2 cases of illness considered to be atypical measles which occurred in siblings, a boy and a girl. They had the same history of vaccination (KKL), were exposed at about the same time, and both presented a clinical picture as described (5). In the boy a pulmonary lesion has persisted for more than 1 1/ 2 year after the infection. The girl was the first to fall ill and the nature of her illness was not realized initially but measles infection was suspected when the brother was admitted for a similar disease 2 weeks later. The diagnosis was confirmed about 1 year later during a serological survey on stored serum pairs. Then new specimens were taken and all sera reinvestigated simultaneously. Both siblings had been vaccinated in 1963 when the family lived in New York State. CASE REPORTS Case 1 LiW, a girl born Nov. 11, 1959. Previous illnesses. Mumps in 1963, chickenpox in 1964 and infectious mononucleosis (probably) in 1966. Otitis Scand J Inject Dis 2
162
T . R¢d et al. Reexaminat ion No v. 7 revealed a good cond ition . Th e ESR was 15 mm. Serology. Complement fixation (CF) tests show ed no rise in titres to influ enza A and B, herp es simplex, mumps, varic ella, adeno- and respiratory sync ytial viru ses. PaulBunnell, My coplasma pneumoniae CF and cold agglut ination te sts were negative. CF antib odies to me asles virus were: Date of bleeding Oct . 10,1967 Me asles CF titre 8
Nov. 7,1967 512
D ec. 28, 1968 64
Case 2
Downloaded by [Deakin University Library] at 18:29 07 November 2015
a
Fig. J. LiW , Oct. 25, 1967. Bilateral pulmonary infiltration. Pleural effusion on the left side.
media with myringotomies 6 tim es and frequent throat infections. Present illness. Th e girl was h ospit alized Oc t. 22, 1967, because of suspicion of meningitis after 2 days with fever, nausea and vomiting, headache, drow siness and irritabilit y. She had no catarrhal symptoms. On admission. Th e girl was alert with slight back and neck stiff ness as the only clinic al signs of meningitis. Th e temperature was 40.6°C, th e pul se rate 120, BP 110/55 , Hb 12.5 g/100 ml, WBC 7800, ESR 65 mm /l hour. The spina l fluid showed 7 cells and 20 mg /loo ml of protein. X-ray of th e lungs showed a diffu se density extending over nearly th e entire left lung. On th e right side a perihil ar thickening was found . Ph ysical examinat ion of th e lungs revealed normal findings. The next day bronchial respiration was noted subscapularly on the left side, increasing th e following days. Th e fever continued and the pati ent was prostrated and vomiting. Blood cultures were negative. Penicillin-sensitive St aph ylococcus aureus were demonstrated f rom the nose but penicillin treatment was ineffective. On suspicion of Mycoplasma pneumonia tetracyclines were then given without effect. Another pulmonary X-r ay was carried out Oct . 25; infiltration of th e left upper as well as lower lobe was still dem onstrable and diffu se infiltration in th e right upper lobe (Fig. 1). WBC count was 6600, ESR 47 mm. On the 7th day of illness a fine maculopapular exanthem appeared on the lower abd omen and in the groi ns. Scarlet fever was suspected as the tongue this tim e showed a white fur and protruding papillae. A sh ift to chloramphenicol was dec ided mainly because of the persisting pulmonary findings. Later th e same day the temperature fell lyrically and subsequently she was afebrile with marked improvement in her condition. X-ray examination on Oct. 31 showed marked clearing of the lungs and no exudate (Fig . 2), and the patient was discharged on Nov. 3.
Scand J In fect Dis 2
LaW , boy born June 9, 1958, brother of patient 1. Previous illnesses. Mumps in 1963, chickenpox in 1964. Present illness. The boy was hospitalized on Nov. 6, 1967, after 3 days with high fever, incre asing somnolence and h allucin ations, photophobia, thoracic pa ins and dry cough. In itially he was treated by the famil y physician with tetracycline s. On admission to the Pediatric Department me asles was suspected and the patient was immediately tr ansf erred to the Department of Infectious Diseases and subjected to its routine of investigation.' On admission . The boy was somnolent and prostr ated but adequately answering questions. Bilateral conjunctival injection and redness of the tongue were seen. The temperature was 39.4°C, the pulse rate 120, and the BP 115/ 60. Crepitant ral es were auscultated over both lungs . A fine maculopapular exanthem appeared round the distal part of the legs as well as on both ankles and on dorsum pedis. Solit ary maculopapules and vesicles were found on the trunk . N o Kopli k's spots were seen but measles was suspec ted. Hb was 12.7 g/100 ml, WBC 6300 (lyrnpho, We th ank Professor H . Laake, M.D., for kind permission to publi sh the case.
",
F ig. 2. LiW , Oct. 31, 1967. Regression of find ings on previous X-ray.
Downloaded by [Deakin University Library] at 18:29 07 November 2015
A typical measles after vaccination with killed vaccine
163
cytes 12, monocytes 2, granulocytes with rod-shaped nuclei 6 and segmented 60%), ESR 55 mrn. X-rayon admission showed a density in the middle of the left lung, and a smaller density medially in the lower part of the right lung (Fig. 3). Tuberculin tests on Nov. 8, 1967, and on Jan. 11 and 18, and on May 10, 1968, were all negative. The patient had fever the first 3 days in hospital. The condition improved gradually and the boy was discharged Nov. 14. X-ray of the lungs Nov. 13 and Nov. 21, 1967, Jan. 3, 1968, and March 3, 1969, all showed persistence of pulmonary lesions described as either pleural thickening interlobarly or pulmonary infiltration (Figs. 4-6). On Nov. 21, 1967, the ESR was 15 mm, the patient had moderate cough and felt healthy. Serology. Cold agglutination and CF with a lymphogranuloma antigen (Lygranum) were negative. CF antibodies to measles virus were: Date of bleeding Measles CF titre
Nov. 6, 1967 32
Dec. 28, 1968 128
Epidemiology An epidemic of measles was going on in the Oslo area when the siblings contracted their disease. Playmates of both the girl as well as the boy became ill with typical measles one day after our patients. The boy may possibly have been infected from his sister.
DISCUSSION
Fig. 4. LaW, Nov. 13, 1967. Infiltration more distinct. Some interlobar fluid.
patients must be characterized as severe with prostration, pneumonia with pleural effusion and high fever. Both had atypical and abortive exanthems and the boy has furthermore persistent pulmonary changes as documented by X-ray investigation for more than 1 1/ 2 year after the
The clinical picture presented by the two siblings fits well with that described by Fulginiti et al. (5). The diagnosis is serologically proved for the girl and is also very likely for the boy and substantiated epidemiologically. The disease in both
Fig. 3. LaW, Nov. 6, 1967. Left-sided pulmonary infiltration on day of admittance. (Picture taken in bed.)
Fig. 5. LaW, Nov. 21, 1967. On lateral view it can be seen that the infiltration is localized to the anterior segment of the left upper lobe. The infiltration seems to be still more circumscribed and there is less interlobar fluid.
Scand J Infect Dis 2
Downloaded by [Deakin University Library] at 18:29 07 November 2015
164
1'. R¢!d et al. organisms in connection with later appearance of the corresponding infection. It has been reported with respiratory syncytial virus (3, 6, 12, 13, 18), trachoma (9), and Mycoplasma pneumoniae (20). The reactions are certainly of immunological nature because of their specificity, but the exact mechanisms involved are not known. Hypersensitivity reactions in connection with low humoral antibody levels have been blamed (7, 11). Others have stressed that circulating antibodies may develop earlier upon infection in prior recipients of inactivated vaccine (2). Virus and antibody may thus be present in the lung at the same time creating an unusual situation with development of pneumonia not seen in natural infection. The accelerated antibody response might even prevent or modify the rash. Finally, misrepresentation of the right antigens in the killed vaccine may be involved (8). Absence of IgA antibodies in the respiratory tract (1) may also be a contributing factor. The paradoxical reactions have never been reported after the use of live vaccines .
Fig. 6. LaW, Jan. 3, 1968. Persistence of the infiltration.
REFERENCES acute illness. Tuberculin tests and th e course of the illness exclude tuberculosis. The frequency of the atypical illness in Kvaccinated children exposed to natural measles has been reported to be quite high. Rauh and Schmidt (19) reported 8 cases of atypical measles among 125 exposed about 2 years after KKK, and 1 case among 9 exposed after KKK-K, the last injection given as a booster 1 year after the others. Fulginiti et al. (5) suspected that the reported cases represent a fraction of the total number that occurred because of the difficulty in diagnosing the illness as measles. The disease usually defies diagnosis unless suspected and appropriate virologic tests are performed. Our patients, born 1958 and 1959 and given KKL in 1963, were probably exposed at 2 weeks interval in 1967, and both contracted atypical measles. There has been no other reports from Norway of similar reactions probably because K has not been used. A few cases have been reported from Sweden (14, 17) in connection with trials with killed vaccine. Atypical reactions have also been seen after immunization with killed vaccines of other microScand J Infect Dis 2
1. Bellanti , J. A , Sanga, R. L., Klutinis, B., Brandt, B. & Artenstein, M . S.: Antibody responses in serum and nasal secretions of children immunized with inactivated and attenuated measles virus vaccines . New Eng J Med 280: 628, 1969. 2. Chanock , R. M., Parrot, R. H ., Kapikian, A. Z., Kin, H. W. & Brandt, C. D.: Possible role of immunological factors in pathogenesis of RS virus lower respiratory tract disease. In: Virus-induced immunopathology. Perspectives of virology VI, p. 125 (ed, M. Pollard). Academic Press, London and New York 1968. 3. Chin, J ., Magoffin, R. L., Shearer, L. A, Schieble, J. H . & Lennette, E. H.: Field evaluation of a respiratory syncytial virus and a trivalent parainfluenza virus vaccine in a pediatric population. Amer J Epidem 99: 449, 1969. 4. Fulginiti, V. A., Arthur, J., Perlman, D. S. & Kempe , C. H.: Serious local reactions following live measles immunization in previously killed-vaccine recipients. J Pediat 69: 891, 1966. 5. Fulginiti, V. A , Eller, J. J., Downie, A W. & Kempe, C. H.: Altered reactivity to measles virus. JAMA 202: 1075, 1967. 6. Fulginiti, V. A, Eller, J. J., Sieber, O. F ., Joyner, J. W., Minamitani, M. & Meiklejohn, G .: Respiratory virus immunization. 1. A field trial of two inactivated respiratory virus vaccines: an aqueous trivalent parainfluenza virus and an alum-precipitated respiratory syncytial virus vaccine. Amer J Epidem 99: 435, 1969.
Downloaded by [Deakin University Library] at 18:29 07 November 2015
Atypical measles after vaccination with killed vaccine 7. Fulginiti, V. A. & Arthur, J. H.: Altered reactivity to measles virus. Skin reactivity and antibody response to measles antigens in recipients of killed measles vaccine. J Pediat 75: 609, 1969. 8. Gard, S.: Vaccination mot massling (I): Satsa pa utveckling av inaktiverat vaccin. Lakartidn 65: 4897, 1968. 9. Grayston, J. T., Woolridge, R L. & Wang, S.: Trachoma vaccine studies in Taiwan. Ann NY Acad Sci 98: 352, 1962. 10. Harris, M. J.: Reactions to live measles vaccine in children previously given killed measles vaccine. Med J Aust 2: 989, 1967. II. Isacson, P.: Delayed dermal hypersensitivity after viral immunization. In: Virus-induced immunopathology. Perspectives of virology VI, p. 141 (ed. M. Pollard). Academic Press, London and New York 1968. 12. Kapikian, A. Z., Mitchell, R. H., Chanock, R. M., Shvedoff, R. A. & Stewart, C. E.: An epidemiologic study of altered clinical reactivity to respiratory syncytial (RS) virus infection in children previously vaccinated with an inactivated RS virus vaccine. Amer J Epidem 99: 405, 1969. 13. Kim, H. W., Canchola, J. G., Brandt, C. D., Pyles, G., Chanock, R M., Jensen, K. & Parrot, R. H.: Respiratory syncytial virus disease in infants despite prior administration of antigenic inactivated vaccine. Amer J Epidem 99: 422, 1969. 14. Lundback, H.: Vaccination mot massling (2): Levande vaccin att foredra. Lakartidn 65: 4905, 1968.
165
15. McNair Scott, T. F. & Bonanno, D. E.: Reactions to live-measles-virus vaccine in children previously inoculated with killed-virus vaccine. New Eng J Med 277: 248, 1967. 16. Nader, P. R, Horwitz, M. S. & Rousseau, J.: Atypical exanthem following exposure to natural measles: Eleven cases in children previously inoculated with killed vaccine. J Pediat 22: 22, 1968. 17. Norrby, E., Lagercrantz, R & Gard, S.: Measles vaccination VI. Serological and clinical follow-up analysis 18 months after a booster injection. Acta Paediat Scand 55: 457, 1966. 18. Parrot, R. H., Kin, H. W., Arrobio, J. 0., Canchola, J. G., Brandt, C. D., deMeie, J. L., Jensen, K. E. & Chanock, R. M.: Experience with inactivated respiratory syncytial and parainfluenza virus vaccines in infants. In: Vaccines against viral and rickettsial diseases of man. Scientific Publication No. 147, p. 35 (ed. A. Horwitz). Pan American Health Organization, Washington D.C. 1967. 19. Rauh, L. W. & Schmidt, R: Measles immunization with killed virus vaccine. Amer J Dis Child 109: 232, 1965. 20. Smith, C. B., Friedewald, W. T. & Chanock, R. M.: Inactivated Mycoplasma pneumoniae vaccine, evaluation in volunteers. JAMA 199: 353, 1967. T. R¢d, M.D., Medical Department, Sentralsykehuset i Akershus, 1474 Nordbyhagen, Norway
Scand J Infect Dis 1
