Journal Article Annotations
2022, 4th Quarter
Annotations by Jeylan Close, MD
This article reviews the pathogenesis, symptoms, possible sequelae, prevention, diagnosis, and management of measles. The article reminds readers that it is highly contagious, spread via aerosol droplets (proper PPE includes N-95 masks), and invades respiratory, neurologic, and immunologic cells. Measles symptoms often include fever, cough, coryza, Koplik spots (blue-white spots on the buccal mucosa), maculopapular rash, diarrhea, and otitis media. Children less than 5 years old and immunocompromised individuals are at increased risk of neurologic symptoms, which are associated with increased risk of death. There are 4 types of measles related encephalitis: primary measles encephalitis, acute post-infectious measles encephalitis (APME), measles inclusion body encephalitis (MIBE), and subacute sclerosing panencephalitis (SSPE). Primary measles encephalitis occurs during the primary infection and APME occurs about a week after the initial appearance of symptoms; both occur in about 1 in 1000 infected people and have mortality rates of 10-20%. MIBE is seen most often in people who are immunocompromised and can present months after the initial infection with AMS, seizures, focal neurologic deficits, and ataxia, and has a mortality rate of 75%. SSPE can occur 2-10 years after the initial infection, can present with progressive behavioral and cognitive issues, and carries a mortality rate of 95%. Diagnosis of SSPE can be made using Dyken’s criteria, which includes evaluation of serum and CSF measles antibodies, clinical symptoms, molecular measles testing, and EEG and MRI findings. Authors note there is an association with higher serum IgE levels in children who develop measles related encephalitis. A mainstay of prevention is vaccination, which is 96% effective. Once infected, symptomatic care for fevers, diarrhea, dehydration, and other symptoms is recommended. Additionally, oral vitamin A is recommended during initial infection, which can decrease risk of death by 87% in young children and decrease duration of acute symptoms. APME is immune-mediated and can be treated with corticosteroids and IgG. SSPE has no proven treatment, but there are reports of improvement with ribavirin, Isoprinosine, and intraventricular IFN-a.
Strength and weaknesses:
This article is an overview of types of encephalitis that may occur in relation to a measles infection, though a weakness is that authors did not include methods of how they gathered the information in the manuscript. Additionally, there was limited new information presented, however, there have been relatively few recent advancements in measles treatment. Nevertheless authors did present, with appropriate caution, some antiviral and immunomodulatory medications that have limited evidence with potential to limit progression of the viral measles infection.
With recent outbreaks of measles within the United States, it is important for physicians to be aware of measles sequalae and management. Specifically, for child and adolescent C-L psychiatrists, measles related encephalitis may be cause for consultation. It is important to be familiar with identifying the four main types of measles related encephalitis as well as treatment options and prognostic information.