L E T T E R S TO T H E E D I T O R Clinical notes
"Clinical notes" represent clinical and/or laboratory experiences which can be presented in 200 to 400 words, 3 or 4 references, and, if contributory, one illustration or short table. "Clinical notes" are subject to the same critical peer review and editing as papers published in other sections of TH~ JOURNAL.
Measles encephalitis in an immunized child To the Editor: The reasons for susceptibility to measles in immunized children have been summarized by Plotkin. 1 The two siblings described below had received measles vaccine at 11 and 12 months of age, respectively. Each of them developed measles, which in one was complicated by encephalitis.
CASE REPORTS Sibling 1, J.K. This T&-year-old girl had received measles vaccine without gamma globulin at 11.5 months of age. When first seen on 4/18/75, cough, fever, runny nose, and watery eyes had been present for four days. The classic erythematous maculopapular eruption of measles was present. Koplick spots were not noted. The course was uncomplicated until 4/21/75 when high fever returned. She had a grand mal seizure. Following spontaneous cessation of the seizure, she remained in a comatose state and responded only to deep pain. The generalized erythematous maculopapular eruption was still present. The spinal fluid contained 125 red blood cells/mm 3, 0 white blood cells/mm3; protein concentration of 50 mg/dl; a glucose of 325 mg/dl. Blood sugar, calcium, sodium, blood urea nitrogen, and serum glutamic oxalacetic transaminase values were within normal limits. Cultures from the throat, blood, and cerebrospinal fluid were negative for bacterial pathogens. Virus was not isolated from the cerebrospinat fluid, At the time of admission, an electroencephalogram (EEG) was interpreted as being compatible with spontaneous sleep or the postictal state. On 4/23/75, the spinal fluid contained 1 red blood cell/mm 3, 15 white blood cells/mm :', and a protein concentration of 37 mg/ dl. She remained in deep coma until the fourth hospital day when she became aware of her surroundings and recognized her parents. By the ninth day, she was fully responsive. An EEG on 4/29/75 showed a mild to moderate generalized cerebral dysrhythmia of nonspecific type. One year after onset, the patient was performing normally at school and was without obvious personality changes. No further seizures had occurred, although she continued with phenobarbital therapy.
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The Journal o f P E D 1 A T R I C S Vol. 90, No. 1, pp. 156-166
Sibling 2, R.K. This 6-year-old girl developed classical measles ten days after the onset of Patient J.K.'s first symptoms. She had received live measles vaccine at 12 months of age. Measles antibody titers. Measles HI antibody was measured by a hemagglutination inhibition technique as previously described) Patient J,K. had measles HI titers of 1:640, 1:320, and 1:80 on the sixth, thirteenth, and twenty-fourth day, respectively, after onset. Patient R.K. demonstrated a rise in measles HI titer from 1:20 to 1:640 between the fourth and twenty-fifth day. The sera obtained from Patient J.K. on the sixth and twentyfourth days after onset were absorbed using a method which removes IgG and leaves lgM and lgA? Titers of 1:80 and 1:20 were obtained following absorption. Late convalescent sera from seven other patients were tested concurrently to assess the efficiency of removal of IgG. HI titers of 1:80-1:640 were reduced to < 1:10 after absorption in each of the seven children.
See related articles, pp. 1, 13, and 17. DISCUSSION Measles encephalitis has been reported in an immunized child on at least one other occasion? Severe encephalitis, therefore, can occur in children who have previously received measles vaccine. The susceptibility to measles in Patient J.K. may be attributed to the fact that she was immunized at less than one year of age. Both children in this family developed measles despite the fact that they had received measles vaccine at 11.5 and 12 months of age. Those with a high risk of vaccine failure have been identified and may include 15% of those immunized at 12 months of age?- ~- 4 The demonstration of measles antibody in the IgM and IgA fraction suggests that the serologic response in Patient J.K. was primary and not a booster. This patient was susceptible to measles because the attempt at immunization was probably unsuccessful and not because previously present antibody had waned to unprotective levels. Physicians face the dilemma of how to reach those children who require re-immunization in our highly mobile population. Since measles occurring after vaccine failure may be complicated by encephalitis, all children who do not have accurate documen-
Volume 90 Number 1
Letters to the Editor
tation of the age at which measles immunization was given should be re-immunized. Lawrence A. R. Ross, M.D. RA M B L C Pediatric Medical Group 2420 Samaritan Dr. San Jose, CA 95124 Anne S. Yeager, M.D. Stanford University School of Medicine Stanford, CA REFERENCES
1. Plotkin SA: Failures of protection by measles vaccine, J PEDIA'rR 82:908, 1973. 2. Yeager AS, Davis JH, Ross LAR, et al: An evaluation of measles immunization: successes and failures, JAMA (in press). 3. Ankerst J, Christensen P, Kjellen L, et al: A routine diagnostic test for IgA antibodies to rubella virus: Absorption of Ig G with staphylococcus aureus, J Infect Dis 130:268, 1974. 4. Schluederberg A, Lamm SH, Landrigan PJ, et al: Measles immunity in children vaccinated before one year of age, Am J Epidemiol 97:402, 1973.
Oligohydramnios syndrome and esophageal atresia To the Editor: The oligohydramnios syndrome frequently accompanies renal agenesis, but may be absent if obstruction to fetal swallowing coexists? Defects in fetal swallowing could compensate for fetal anuria, preventing oligohydramnios and its effects on the fetus. The oligohydramnios syndrome appearing in an infant with renal dysplasia and esophageal atresia suggests a variable volume balance between fetal micturition and swallowing. CASE REPORT A 15-year-old mother denied recent weight gain or abdominal swelling. Membranes ruptured just before delivery as evidenced by passage of very little amniotic fluid. Estimated gestational age was 36 weeks, weight 1,700 gm, length 42 cm, and frontoccipital circumference 28.5 cm (all
"Clinical notes" represent clinical and/or laboratory experiences which can be presented in 200 to 400 words, 3 or 4 references, and, if contributory, one illustration or short table. "Clinical notes" are subject to the same critical peer review and editing as papers published in other sections of TH~ JOURNAL.
Measles encephalitis in an immunized child To the Editor: The reasons for susceptibility to measles in immunized children have been summarized by Plotkin. 1 The two siblings described below had received measles vaccine at 11 and 12 months of age, respectively. Each of them developed measles, which in one was complicated by encephalitis.
CASE REPORTS Sibling 1, J.K. This T&-year-old girl had received measles vaccine without gamma globulin at 11.5 months of age. When first seen on 4/18/75, cough, fever, runny nose, and watery eyes had been present for four days. The classic erythematous maculopapular eruption of measles was present. Koplick spots were not noted. The course was uncomplicated until 4/21/75 when high fever returned. She had a grand mal seizure. Following spontaneous cessation of the seizure, she remained in a comatose state and responded only to deep pain. The generalized erythematous maculopapular eruption was still present. The spinal fluid contained 125 red blood cells/mm 3, 0 white blood cells/mm3; protein concentration of 50 mg/dl; a glucose of 325 mg/dl. Blood sugar, calcium, sodium, blood urea nitrogen, and serum glutamic oxalacetic transaminase values were within normal limits. Cultures from the throat, blood, and cerebrospinal fluid were negative for bacterial pathogens. Virus was not isolated from the cerebrospinat fluid, At the time of admission, an electroencephalogram (EEG) was interpreted as being compatible with spontaneous sleep or the postictal state. On 4/23/75, the spinal fluid contained 1 red blood cell/mm 3, 15 white blood cells/mm :', and a protein concentration of 37 mg/ dl. She remained in deep coma until the fourth hospital day when she became aware of her surroundings and recognized her parents. By the ninth day, she was fully responsive. An EEG on 4/29/75 showed a mild to moderate generalized cerebral dysrhythmia of nonspecific type. One year after onset, the patient was performing normally at school and was without obvious personality changes. No further seizures had occurred, although she continued with phenobarbital therapy.
156
The Journal o f P E D 1 A T R I C S Vol. 90, No. 1, pp. 156-166
Sibling 2, R.K. This 6-year-old girl developed classical measles ten days after the onset of Patient J.K.'s first symptoms. She had received live measles vaccine at 12 months of age. Measles antibody titers. Measles HI antibody was measured by a hemagglutination inhibition technique as previously described) Patient J,K. had measles HI titers of 1:640, 1:320, and 1:80 on the sixth, thirteenth, and twenty-fourth day, respectively, after onset. Patient R.K. demonstrated a rise in measles HI titer from 1:20 to 1:640 between the fourth and twenty-fifth day. The sera obtained from Patient J.K. on the sixth and twentyfourth days after onset were absorbed using a method which removes IgG and leaves lgM and lgA? Titers of 1:80 and 1:20 were obtained following absorption. Late convalescent sera from seven other patients were tested concurrently to assess the efficiency of removal of IgG. HI titers of 1:80-1:640 were reduced to < 1:10 after absorption in each of the seven children.
See related articles, pp. 1, 13, and 17. DISCUSSION Measles encephalitis has been reported in an immunized child on at least one other occasion? Severe encephalitis, therefore, can occur in children who have previously received measles vaccine. The susceptibility to measles in Patient J.K. may be attributed to the fact that she was immunized at less than one year of age. Both children in this family developed measles despite the fact that they had received measles vaccine at 11.5 and 12 months of age. Those with a high risk of vaccine failure have been identified and may include 15% of those immunized at 12 months of age?- ~- 4 The demonstration of measles antibody in the IgM and IgA fraction suggests that the serologic response in Patient J.K. was primary and not a booster. This patient was susceptible to measles because the attempt at immunization was probably unsuccessful and not because previously present antibody had waned to unprotective levels. Physicians face the dilemma of how to reach those children who require re-immunization in our highly mobile population. Since measles occurring after vaccine failure may be complicated by encephalitis, all children who do not have accurate documen-
Volume 90 Number 1
Letters to the Editor
tation of the age at which measles immunization was given should be re-immunized. Lawrence A. R. Ross, M.D. RA M B L C Pediatric Medical Group 2420 Samaritan Dr. San Jose, CA 95124 Anne S. Yeager, M.D. Stanford University School of Medicine Stanford, CA REFERENCES
1. Plotkin SA: Failures of protection by measles vaccine, J PEDIA'rR 82:908, 1973. 2. Yeager AS, Davis JH, Ross LAR, et al: An evaluation of measles immunization: successes and failures, JAMA (in press). 3. Ankerst J, Christensen P, Kjellen L, et al: A routine diagnostic test for IgA antibodies to rubella virus: Absorption of Ig G with staphylococcus aureus, J Infect Dis 130:268, 1974. 4. Schluederberg A, Lamm SH, Landrigan PJ, et al: Measles immunity in children vaccinated before one year of age, Am J Epidemiol 97:402, 1973.
Oligohydramnios syndrome and esophageal atresia To the Editor: The oligohydramnios syndrome frequently accompanies renal agenesis, but may be absent if obstruction to fetal swallowing coexists? Defects in fetal swallowing could compensate for fetal anuria, preventing oligohydramnios and its effects on the fetus. The oligohydramnios syndrome appearing in an infant with renal dysplasia and esophageal atresia suggests a variable volume balance between fetal micturition and swallowing. CASE REPORT A 15-year-old mother denied recent weight gain or abdominal swelling. Membranes ruptured just before delivery as evidenced by passage of very little amniotic fluid. Estimated gestational age was 36 weeks, weight 1,700 gm, length 42 cm, and frontoccipital circumference 28.5 cm (all
