title: Acute measles encephalitis in partially vaccinated adults.
abstract: BACKGROUND
  The pathogenesis of acute measles encephalitis (AME) is poorly understood. Treatment with immune-modulators is based on theories that post-infectious autoimmune responses cause demyelination. The clinical course and immunological parameters of AME were examined during an outbreak in Vietnam.
  
  
  RESULTS
  Fifteen measles IgM-positive patients with confusion or Glasgow Coma Scale (GCS) score below 13, and thirteen with uncomplicated measles were enrolled from 2008-2010. Standardized clinical exams were performed and blood collected for lymphocyte and measles- and auto-antibody analysis. The median age of AME patients was 21 years, similar to controls. Eleven reported receiving measles vaccination when aged one year. Confusion developed a median of 4 days after rash. Six patients had GCS <8 and four required mechanical ventilation. CSF showed pleocytosis (64%) and proteinorrhachia (71%) but measles virus RNA was not detected. MRI revealed bilateral lesions in the cerebellum and brain stem in some patients. Most received dexamethasone +/- IVIG within 4 days of admission but symptoms persisted for ≥3 weeks in five. The concentration of voltage gated calcium channel-complex-reactive antibodies was 900 pM in one patient, and declined to 609 pM ∼ 3 months later. Measles-reactive IgG antibody avidity was high in AME patients born after vaccine coverage exceeded 50% (∼ 25 years earlier). AME patients had low CD4 (218/µl, p = 0.029) and CD8 (200/µl, p = 0.012) T-cell counts compared to controls.
  
  
  CONCLUSIONS
  Young adults presenting with AME in Vietnam reported a history of one prior measles immunization, and those aged <25 years had high measles-reactive IgG avidity indicative of prior vaccination. This suggests that one-dose measles immunization is not sufficient to prevent AME in young adults and reinforces the importance of maintaining high coverage with a two-dose measles immunization schedule. Treatment with corticosteroids and IVIG is common practice, and should be assessed in randomized clinical trials.
authors: Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City and Ha Noi, Viet Nam. afox@oucru.org
authors: Annette
authors: A
authors: Fox
authors: Than Manh
authors: TM
authors: Hung
authors: Heiman
authors: H
authors: Wertheim
authors: Le Nguyen Minh
authors: le NM
authors: Hoa
authors: Angela
authors: A
authors: Vincent
authors: Bethan
authors: B
authors: Lang
authors: Patrick
authors: P
authors: Waters
authors: Nguyen Hong
authors: NH
authors: Ha
authors: Nguyen Vu
authors: NV
authors: Trung
authors: Jeremy
authors: J
authors: Farrar
authors: Nguyen
authors: N
authors: Van Kinh
authors: Peter
authors: P
authors: Horby
mesh_terms: D000208:Acute Disease; D000328:Adult; D001921:Brain / Q000473:pathology; D016022:Case-Control Studies; D018450:Disease Progression; D004660:Encephalitis / Q000150:complications / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D005260:Female; D006801:Humans; D018655:Lymphocyte Count; D008279:Magnetic Resonance Imaging; D008297:Male; D008457:Measles / Q000150:complications* / Q000276:immunology* / Q000517:prevention & control; D008458:Measles Vaccine / Q000008:administration & dosage / Q000276:immunology*; D016896:Treatment Outcome; D014611:Vaccination; D055815:Young Adult
chemical_list: D008458:Measles Vaccine
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