A case of unusual, complicated adult measles during a measles outbreak in Ndala hospital, Tanzania

Measles is a highly infectious viral disease which can have serious complications. Immunization is effective, but outbreaks can occur when there is low vaccination coverage.[1-3] Measles is still one of the major contributors to childhood morbidity and mortality,4,5 with almost 140,000 deaths worldwide in 2010.6

In 2011 and 2012, for the first time in 20 years, an outbreak of measles was observed in Ndala Hospital, a district-size mission hospital with 128 beds. All patients came from villages in Nzega and Uyui districts of the central plateau of Tanzania. Among the patients was an unexpected large number of adults. Here we describe a case of adult measles with a serious complication.

Case

A twenty-two year old, previously healthy man was admitted to our hospital with a generalized rash, fever and cough. On examination the patient appeared ill and febrile. He had bilateral conjunctivitis and a generalized confluent maculopapular rash. On auscultation of the lungs bilateral crepitations were heard. The HIV-test was negative. Because he came from a village where other cases of adult measles had been reported, complicated measles was diagnosed given the clinical findings. Treatment was started with vitamin A tablets, tetracycline eye ointment and oral benzylpenicillin and gentamicin.

Two days after admission the fever had disappeared, but the skin of the upper torso and neck became swollen and tender to touch. The chest X-ray showed signs of bronchopneumonia with subcutaneous emphysema without pneumothorax or pneumomediastinum. Since there was no respiratory distress, the same management was continued. When the patient was discharged from hospital three days later, he was in good condition, but he still had some pain at the site of the subcutaneous emphysema.

Measles outbreak

From 2011 to 2012 in total 185 patients were admitted to our hospital with the diagnosis of measles. The diagnosis was made by the clinicians using clinical symptoms (fever, pulmonary symptoms, coryza, conjunctivitis and typical rash), vaccination status and exposure to measles.7 Most of them (161) were young children, of whom 9 died (5.6%). During the same period, we admitted 24 adults with measles, of whom I died (4.2%). In 5 cases, an HIV-test was performed because of clinical suspicion. However, all tests were negative. Most patients recovered with antipyretics and sometimes (oral or intravenous) antibiotics to treat secondary bacterial pneumonia. Two pregnant women probably suffered from obstetric complications due to a measles infection. One delivered a fresh stillbirth and the other delivered a premature child.

Discussion

Through increased vaccination efforts, the incidence of measles has been reduced worldwide. To achieve eradication in 2020, the target for WHO member states for 2010 was to reduce measles mortality by 90% and in 2015 by 95% from the 2000 estimates. 6,8 The first target was already met in the African Region in 2006, but only a small decrease in mortality followed in 2009 and 2010.6,8 We were unable to obtain district vaccination coverage figures, but for the Ndala-ward the measles vaccination coverage was 66% in 2011.9 In the referral area of Ndala hospital access to education and health services is poor. Many people do not speak Swahili, which can contribute to lack of knowledge about vaccinations. A low level of education of the head of the household and a low family income, both of which are common in our area, have been previously described as the most important predictors for completion of immunization.o

In our hospital 10 (5.4%) patients infected with the measles died. In other reports the case fatality rate of measles varies from 0.3% in developed countries to up to 28% in community-based studies in developing countries.” Differences can be caused by prevalence of malnutrition and vitamin A deficiency, which contribute significantly to the mortality.11In the literature the most common complications which often lead to death are pneumonia, bronchitis and encephalitis. 11-13 In our hospital most patients died of respiratory infections and following distress.

Severe measles is more common and has a higher fatality rate in immunocompromised patients.” HIV-infected persons with concomitant measles infection are more likely to have more uncharacteristic clinical findings and more severe measles infection, with high rates of pneumonitis and death.¹⁴ Since only 5 of our patients with measles infection were tested for concomitant HIV infection, we do not exactly know the percentage of concomitant HIV infection. However, given the relatively low HIV prevalence in our area (3.1% of pregnant women), we assume that this percentage would not be very high. 9

We reported a case of subcutaneous emphysema as a complication of measles. Subcutaneous emphysema secondary to measles is a rare complication, and only few cases have been reported. 15,16 It may be caused by severe coughing episodes (pressure gradient theory). 15,17 In children it accounts for about 6.4% of complications, mostly in the malnourished. 16 In adults the estimated prevalence is 2%,2 and it is associated with poor outcomes due to airway obstruction. 13,16

In a population without vaccinations measles usually occurs in epidemics every few years, with mostly children affected. When vaccination coverage is incomplete an epidemic, many years after the previous one, will also affect young adults. This has recently also been described in Malawi. 18 Measles in adult patients is usually seen in unvaccinated people, 3,19 although infection can also occur after adequate vaccination, especially in HIV-infected individuals. 14,20 In adults many complications are documented, mostly pulmonary. 12, 13, 21-23

Conclusion

Measles is best known as an infection of young children, being most dangerous in the malnourished. In the absence of regular epidemics inadequate vaccination coverage resulting in an incidental epidemic can cause adults to suffer as well, with sometimes serious complications.

Acknowledgements

The authors acknowledge the support of the staff of Ndala Hospital in general and especially of Danielle van den Hamer (Nursing Officer), who helped with the data collection.

References

Full list of references can be obtained from the author.

1. Stein-Zamir C, Zentner G, Abramson N, et al. Measles outbreaks affecting children in Jewish ultra-orthodox communities in Jerusalem. Epidemiol Infect 2008;136(2):207-214.
2. Sutherland AG, Barnabas K, Haribhaskar K. Measles: an adult case during a local outbreak. BMJ Case Rep 2009:bcr02.2009.1559.
3. Tan JB, Cao WH, Pang ZC, et al. Study on the relative risk factors of adult measles in a case-control study in Qingdao city. Zhonghua Liu Xing Bing Xue Za Zhi 2006;27(3):226-229.