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Concurrent infectious mononucleosis and measles: a potentially life-threatening association sharing underlying immunodeficiency

Manfredi, Roberto M.D.; Coronado, Olga V. M.D.; Mastroianni, Antonio M.D.; Chiodo, Francesco M.D.

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The Pediatric Infectious Disease Journal: May 2003 - Volume 22 - Issue 5 - p 470-471
doi: 10.1097/01.inf.0000066873.64509.51
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We report lethal interstitial pneumonia in an 18-year-old young man with measles infection following recent infectious mononucleosis. We speculate that the documented T cell immune impairment caused by the concurrent Epstein-Barr and measles viral infections (as expressed by a proportionally low CD4+ lymphocyte count) was responsible for the complicated clinical course and unfavorable outcome.

Primary viral pneumonia is an infrequent, potentially life-threatening complication of measles, 1 especially when primary or secondary immunodeficiency is present. Extensive involvement of lower respiratory tract (characterized by a bronchiolitis or interstitial pneumonia) is the most common feature, and bacterial superinfection may be a further complication.

Case report.

An 18-year-old male patient who had not received active measles immunization developed infectious mononucleosis, that was treated with low dose corticosteroid therapy (methylprednisolone at 8 mg/day), because of severe lymph node and tonsillar hypertrophy leading to dysphagia and associated hyperpyrexia. Ten days after the onset of infectious mononucleosis, our patient was hospitalized because of suspected measles. He had been exposed to measles in his household setting and had fever and the appearance of extensive mucositis and a petechial enanthem. Laboratory examination showed a positive Monotest, specific Epstein-Barr virus (EBV) IgM antibodies (1/480) and leukocytosis characterized by elevated lymphocyte (45%) and monocyte (11%) counts. There was a depleted CD4+ T lymphocyte subset (16.7%, with an absolute count of 304 cells/μl), with a concurrent increase of CD8+ cell count and a reversal of the CD4+:CD8+ ratio (0.62) in the absence of other significant laboratory, immunologic and microbiologic findings, save a slight increase of liver function tests. At the time of hospitalization clinical and radiologic chest examinations were normal, but four days later a macular-papular exanthem extending from face to trunk to limbs became apparent, in association with Köplik’s buccal lesions and especially an increasing dry cough and mounting dyspnea. The chest roentgenogram showed diffuse bilateral interstitial alveolar infiltrates. Measles serology tested positive for IgM antibody (titer, 1/640). In spite of intensive supportive treatment with mechanical ventilation and broad spectrum antimicrobial coverage, pulmonary involvement rapidly progressed with severe dyspnea, hypoxemia (pO2 levels <60 mm Hg and hemoglobin saturation <80%) and radiographic evidence of extensive bilateral interstitial disease, complicated by pneumothorax. The severe respiratory failure led to death 3 weeks after admission. Necropsy finding confirmed the measles etiology of the severe respiratory complication, showing the typical histopathologic picture of giant multinucleated cells, with intranuclear inclusion bodies.

Discussion.

In a medical literature search, we found a single case of severe measles pneumonia following intrafamilial contagion in a 17-year-old young man with recent infectious mononucleosis. 1 No lethal reports after the combination of these two viral diseases have been previously described. The incidence and severity of primary measles pneumonia are related to the host immune response. An underlying immunodeficiency resulting in a transient impairment of T cell-mediated immune defense and prompted by infectious mononucleosis 2–4 and measles 5–7 mostly likely accounted for the unfavorable clinical evolution in this patient. The concurrence of multiple risk factors (young adult age, no prior measles vaccination, concomitant EBV infection and steroid therapy, even in low dosage), undoubtedly predisposed this patient to the respiratory complications. In contrast steroid therapy was apparently successful in the above mentioned literature case report of severe measles pneumonia occurring in a patient with concurrent infectious mononucleosis. 1 The EBV-related immunodeficiency, 2–4 although moderate and transient, can predispose to a greater risk of infectious complications, especially bacterial superinfection of the upper and lower airways. 3, 4

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2. Verucchi G, Attard L, Maldini M, et al. Cell-mediated immunity in infectious mononucleosis. Adv Exp Med Biol 1989; 257: 279–88.
3. Gruber R, Krauss-Etschmann S, Jager G, Belohradsky BH, Koletzko S. Atypical CD3+CD4low cell population in a boy with fatal EBV infection. Int Arch Allergy Immunol 1999; 118: 74–8.
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5. Fujinami RS, Sun X, Howell JM, Jenkin JC, Burns JB. Modulation of immune system function by measles virus infection: role of soluble factor and direct infection. J Virol 1998; 72: 9421–7.
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Keywords:

Infectious mononucleosis; measles; immunodeficiency; complication; pneumonia; case report; mortality

© 2003 Lippincott Williams & Wilkins, Inc.