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Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients.

Rafat C, Klouche K, Ricard JD, Messika J, Roch A, Machado S, Sonneville R, Guisset O, Pujol W, Guérin C, Teboul JL, Mrozek N, Darmon M, Chemouni F, Schmidt M, Mercier E, Dreyfuss D, Gaudry S - Medicine (Baltimore) (2013)

Bottom Line: Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS).Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases.Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality.

View Article: PubMed Central - PubMed

Affiliation: From AP-HP, Service de Réanimation Médico-Chirurgicale, Université Paris Diderot, Sorbonne Paris Cité Hôpital Louis Mourier, Colombes (CR, JDR, JM, DD, SG); Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier (KK, SM); Institut National de la Santé et de la Recherche Médicale, INSERM U722, Paris (JDR, JM, DD, SG); Universite Paris Diderot, Sorbonne Paris Cité, UMR 722, Paris (JDR, JM, DD, SG); AP-HP, Service de Pneumologie et Réanimation, Hôpital Tenon, Universite Pierre-et-Marie-Curie, Paris (JM); Aix-Marseille Université, Faculté de Médecine, URMITE UMR CNRS 7278, Marseille, and APHM, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Marseille (AR); AP-HP, Service de Réanimation Médicale et des Maladies Infectieuses, Université Paris Diderot, Sorbonne Paris Cité, Hôpital Bichat-Claude-Bernard, Paris (RS); Service de Réanimation Médicale, Hôpital Saint-André, CHU Bordeaux, Bordeaux (OG); Service d'Anesthésie et Réanimation, Polyclinique Bordeaux Nord Aquitaine, Bordeaux (WP); Hospices Civils de Lyon, Service de Réanimation Médicale, Hôpital de la Croix Rousse, Lyon (CG); AP-HP, Hôpital de Bicêtre, Service de Réanimation Médicale, Le Kremlin-Bicêtre (JLT); CHU Clermont-Ferrand, Unité de Réanimation Médicale, Pôle REUNNIRH, Hôpital G Montpied, Clermont-Ferrand (NM); Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, and Jean Monnet University, Saint-Etienne (MD); Medico-Surgical Intensive Care Unit, Avicenne Teaching Hospital, Bobigny (FC); AP-HP, Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Paris (MS); and Medical Intensive Care Unit, Tours University Hospital, Tours (EM); France.

ABSTRACT
France has recently witnessed a nationwide outbreak of measles. Data on severe forms of measles in adults are lacking. We sought to describe the epidemiologic, clinical, treatment, and prognostic aspects of the disease in adult patients who required admission to an intensive care unit (ICU). We performed a retrospective analysis of a cohort of 36 adults admitted to a total of 64 ICUs throughout France for complications of measles from January 1, 2009, to December 31, 2011. All cases of measles were confirmed by serologic testing and/or reverse transcription polymerase chain reaction.The cohort consisted of 21 male and 15 female patients, with a median age of 29.2 years (25th-75th interquartile range [IQR], 27.2-34.2 yr) and a median Simplified Acute Physiology Score (SAPS II) of 13 (IQR, 9-18). Among the 26 patients whose measles vaccination status was documented, none had received 2 injections. One patient had developed measles during childhood. Underlying comorbid conditions included chronic respiratory disease in 9 patients, immunosuppression in 7 patients, and obesity in 3 patients, while measles affected 5 pregnant women.Respiratory complications induced by measles infection led to ICU admission in 32 cases, and measles-related neurologic complications led to ICU admission in 2 cases. Two patients were admitted due to concurrent respiratory and neurologic complications.Bacterial superinfection of measles-related airway infection was suspected in 28 patients and was documented in 8. Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS). Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases. Five patients died, all of whom were severely immunocompromised.On follow-up, 1 patient had severe chronic respiratory failure related to lung fibrosis, and 2 patients had mild lower limb paraparesis along with bladder dysfunction, both of which were ascribable to measles-induced encephalitis and myelitis. Among the 5 pregnant patients, the course of measles infection was uneventful, albeit 1 patient underwent emergent cesarean delivery because of fetal growth restriction.Measles is a disease with protean and potentially deceptive clinical manifestations, especially in the immunocompromised patient. Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality. In contrast with the usually benign course of the disease in immunocompetent patients, measles occurring in immunocompromised patients gives rise to lethal complications including ARDS, with or without bacterial superinfection. Other patients potentially at high risk for severe measles are young adults and pregnant women. Measles pneumonitis may predispose to air leak disease in patients using mechanical ventilation. To date, vaccination remains the most potent tool to control measles infection.

No MeSH data available.


Related in: MedlinePlus

Typical aspects of measles pneumonitis on CT scan. A1. Scan from a 27-year-old kidney transplant patient, on admission to the ICU: interstitial pneumonitis with disseminated micronodular distribution. A2. Follow-up chest CT scan 3 months after ICU admission: fibrosing interstitial pneumonia with micronodules, thickened interlobular septa, and focal areas of retraction. B1. Scan from an 18-year-old patient with common variable immunodeficiency, on admission to the ICU: interstitial pneumonitis with bilateral reticulonodular infiltrates and ground-glass opacities and lung consolidation of the lower right lung. B2. Scan from Day 21 after admission to the ICU: right hemothorax with chest tube, bilateral bronchiectasis, and cystic lesions of the lungs. C1. Scan from 30-year-old kidney transplant patient, on admission to the ICU: bilateral, alveolar, and interstitial opacities with a predominantly perihilar distribution.
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Figure 2: Typical aspects of measles pneumonitis on CT scan. A1. Scan from a 27-year-old kidney transplant patient, on admission to the ICU: interstitial pneumonitis with disseminated micronodular distribution. A2. Follow-up chest CT scan 3 months after ICU admission: fibrosing interstitial pneumonia with micronodules, thickened interlobular septa, and focal areas of retraction. B1. Scan from an 18-year-old patient with common variable immunodeficiency, on admission to the ICU: interstitial pneumonitis with bilateral reticulonodular infiltrates and ground-glass opacities and lung consolidation of the lower right lung. B2. Scan from Day 21 after admission to the ICU: right hemothorax with chest tube, bilateral bronchiectasis, and cystic lesions of the lungs. C1. Scan from 30-year-old kidney transplant patient, on admission to the ICU: bilateral, alveolar, and interstitial opacities with a predominantly perihilar distribution.

Mentions: All patients except 2 underwent thoracic imaging within 24 hours of ICU admission. Chest CT scan results were readily available for 10 patients. Typical aspects of measles pneumonitis are displayed in Figure 2. Thoracic imaging among patients admitted for measles disclosed an exclusive pattern of interstitial pneumonitis in 21 (61.7%) cases. In all but 1 patient, chest CT scans, when performed, disclosed evidence of interstitial lesions. Of 9 patients, the pattern of interstitial pneumonitis consisted of micronodular opacities (n = 4), ground-glass opacities (n = 4), and reticulonodular lesions (n = 3). Mixed alveolar and interstitial lesions were seen in 4 (11.7%) cases. Lesions, when present, were predominantly bilateral (89.5%). In this same group of patients, thoracic imaging upon admission did not display any abnormality in 3 cases (21.2%). In all cases, imaging was chest X-Ray exam. In 1 case, a bilateral interstitial lesion pattern was substantiated on follow-up exam, and in the 2 remaining patients, the prevailing diagnosis was measles pneumonitis because of biologically ascertained measles infection, significant hypoxemia, and lack of alternative diagnosis. In the group of patients with CAP along with measles pneumonitis (n = 4), areas of consolidation were noticed in 2 instances. Two patients using mechanical ventilation had repeated CT scans during their stays in the ICU because of persistent and severe hypoxemia. In both cases, in addition to the interstitial lesion pattern initially substantiated, the CT scans demonstrated lobar consolidation of the lower lobes and evidence of fibrosis (thickened septa and retractile bronchiectasis in 1 case, bronchiectasis and disseminated cystic lesions in the other). Neither of these 2 patients had microbiologic evidence of pulmonary superinfection at the time the control chest CT scan was performed.


Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients.

Rafat C, Klouche K, Ricard JD, Messika J, Roch A, Machado S, Sonneville R, Guisset O, Pujol W, Guérin C, Teboul JL, Mrozek N, Darmon M, Chemouni F, Schmidt M, Mercier E, Dreyfuss D, Gaudry S - Medicine (Baltimore) (2013)

Typical aspects of measles pneumonitis on CT scan. A1. Scan from a 27-year-old kidney transplant patient, on admission to the ICU: interstitial pneumonitis with disseminated micronodular distribution. A2. Follow-up chest CT scan 3 months after ICU admission: fibrosing interstitial pneumonia with micronodules, thickened interlobular septa, and focal areas of retraction. B1. Scan from an 18-year-old patient with common variable immunodeficiency, on admission to the ICU: interstitial pneumonitis with bilateral reticulonodular infiltrates and ground-glass opacities and lung consolidation of the lower right lung. B2. Scan from Day 21 after admission to the ICU: right hemothorax with chest tube, bilateral bronchiectasis, and cystic lesions of the lungs. C1. Scan from 30-year-old kidney transplant patient, on admission to the ICU: bilateral, alveolar, and interstitial opacities with a predominantly perihilar distribution.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4553975&req=5

Figure 2: Typical aspects of measles pneumonitis on CT scan. A1. Scan from a 27-year-old kidney transplant patient, on admission to the ICU: interstitial pneumonitis with disseminated micronodular distribution. A2. Follow-up chest CT scan 3 months after ICU admission: fibrosing interstitial pneumonia with micronodules, thickened interlobular septa, and focal areas of retraction. B1. Scan from an 18-year-old patient with common variable immunodeficiency, on admission to the ICU: interstitial pneumonitis with bilateral reticulonodular infiltrates and ground-glass opacities and lung consolidation of the lower right lung. B2. Scan from Day 21 after admission to the ICU: right hemothorax with chest tube, bilateral bronchiectasis, and cystic lesions of the lungs. C1. Scan from 30-year-old kidney transplant patient, on admission to the ICU: bilateral, alveolar, and interstitial opacities with a predominantly perihilar distribution.
Mentions: All patients except 2 underwent thoracic imaging within 24 hours of ICU admission. Chest CT scan results were readily available for 10 patients. Typical aspects of measles pneumonitis are displayed in Figure 2. Thoracic imaging among patients admitted for measles disclosed an exclusive pattern of interstitial pneumonitis in 21 (61.7%) cases. In all but 1 patient, chest CT scans, when performed, disclosed evidence of interstitial lesions. Of 9 patients, the pattern of interstitial pneumonitis consisted of micronodular opacities (n = 4), ground-glass opacities (n = 4), and reticulonodular lesions (n = 3). Mixed alveolar and interstitial lesions were seen in 4 (11.7%) cases. Lesions, when present, were predominantly bilateral (89.5%). In this same group of patients, thoracic imaging upon admission did not display any abnormality in 3 cases (21.2%). In all cases, imaging was chest X-Ray exam. In 1 case, a bilateral interstitial lesion pattern was substantiated on follow-up exam, and in the 2 remaining patients, the prevailing diagnosis was measles pneumonitis because of biologically ascertained measles infection, significant hypoxemia, and lack of alternative diagnosis. In the group of patients with CAP along with measles pneumonitis (n = 4), areas of consolidation were noticed in 2 instances. Two patients using mechanical ventilation had repeated CT scans during their stays in the ICU because of persistent and severe hypoxemia. In both cases, in addition to the interstitial lesion pattern initially substantiated, the CT scans demonstrated lobar consolidation of the lower lobes and evidence of fibrosis (thickened septa and retractile bronchiectasis in 1 case, bronchiectasis and disseminated cystic lesions in the other). Neither of these 2 patients had microbiologic evidence of pulmonary superinfection at the time the control chest CT scan was performed.

Bottom Line: Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS).Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases.Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality.

View Article: PubMed Central - PubMed

Affiliation: From AP-HP, Service de Réanimation Médico-Chirurgicale, Université Paris Diderot, Sorbonne Paris Cité Hôpital Louis Mourier, Colombes (CR, JDR, JM, DD, SG); Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier (KK, SM); Institut National de la Santé et de la Recherche Médicale, INSERM U722, Paris (JDR, JM, DD, SG); Universite Paris Diderot, Sorbonne Paris Cité, UMR 722, Paris (JDR, JM, DD, SG); AP-HP, Service de Pneumologie et Réanimation, Hôpital Tenon, Universite Pierre-et-Marie-Curie, Paris (JM); Aix-Marseille Université, Faculté de Médecine, URMITE UMR CNRS 7278, Marseille, and APHM, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères, Marseille (AR); AP-HP, Service de Réanimation Médicale et des Maladies Infectieuses, Université Paris Diderot, Sorbonne Paris Cité, Hôpital Bichat-Claude-Bernard, Paris (RS); Service de Réanimation Médicale, Hôpital Saint-André, CHU Bordeaux, Bordeaux (OG); Service d'Anesthésie et Réanimation, Polyclinique Bordeaux Nord Aquitaine, Bordeaux (WP); Hospices Civils de Lyon, Service de Réanimation Médicale, Hôpital de la Croix Rousse, Lyon (CG); AP-HP, Hôpital de Bicêtre, Service de Réanimation Médicale, Le Kremlin-Bicêtre (JLT); CHU Clermont-Ferrand, Unité de Réanimation Médicale, Pôle REUNNIRH, Hôpital G Montpied, Clermont-Ferrand (NM); Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, and Jean Monnet University, Saint-Etienne (MD); Medico-Surgical Intensive Care Unit, Avicenne Teaching Hospital, Bobigny (FC); AP-HP, Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Paris (MS); and Medical Intensive Care Unit, Tours University Hospital, Tours (EM); France.

ABSTRACT
France has recently witnessed a nationwide outbreak of measles. Data on severe forms of measles in adults are lacking. We sought to describe the epidemiologic, clinical, treatment, and prognostic aspects of the disease in adult patients who required admission to an intensive care unit (ICU). We performed a retrospective analysis of a cohort of 36 adults admitted to a total of 64 ICUs throughout France for complications of measles from January 1, 2009, to December 31, 2011. All cases of measles were confirmed by serologic testing and/or reverse transcription polymerase chain reaction.The cohort consisted of 21 male and 15 female patients, with a median age of 29.2 years (25th-75th interquartile range [IQR], 27.2-34.2 yr) and a median Simplified Acute Physiology Score (SAPS II) of 13 (IQR, 9-18). Among the 26 patients whose measles vaccination status was documented, none had received 2 injections. One patient had developed measles during childhood. Underlying comorbid conditions included chronic respiratory disease in 9 patients, immunosuppression in 7 patients, and obesity in 3 patients, while measles affected 5 pregnant women.Respiratory complications induced by measles infection led to ICU admission in 32 cases, and measles-related neurologic complications led to ICU admission in 2 cases. Two patients were admitted due to concurrent respiratory and neurologic complications.Bacterial superinfection of measles-related airway infection was suspected in 28 patients and was documented in 8. Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS). Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases. Five patients died, all of whom were severely immunocompromised.On follow-up, 1 patient had severe chronic respiratory failure related to lung fibrosis, and 2 patients had mild lower limb paraparesis along with bladder dysfunction, both of which were ascribable to measles-induced encephalitis and myelitis. Among the 5 pregnant patients, the course of measles infection was uneventful, albeit 1 patient underwent emergent cesarean delivery because of fetal growth restriction.Measles is a disease with protean and potentially deceptive clinical manifestations, especially in the immunocompromised patient. Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality. In contrast with the usually benign course of the disease in immunocompetent patients, measles occurring in immunocompromised patients gives rise to lethal complications including ARDS, with or without bacterial superinfection. Other patients potentially at high risk for severe measles are young adults and pregnant women. Measles pneumonitis may predispose to air leak disease in patients using mechanical ventilation. To date, vaccination remains the most potent tool to control measles infection.

No MeSH data available.


Related in: MedlinePlus