Giant-cell pneumonia caused by measles and methotrexate in childhood leukaemia in remission

Viral Infections of the Lung

The lungs are among the most vulnerable to microbial assault of all organs in the body. From a contemporary vantage, lower respiratory tract infections are the greatest cause of infection-related mortality in the United States, and rank seventh among all causes of deaths in the United States.2,3 From a global and historic perspective, the scope and scale of lower respiratory tract infection is greater than any other infectious syndrome, and viral pneumonias have proven to be some of the most lethal and dramatic of human diseases. The 1918–1919 influenza pandemic, perhaps the most devastating infectious disease pandemic in recorded history, resulted in an estimated 40 million deaths worldwide, including 700,000 deaths in the U.S.4 The global outbreak of severe acute respiratory syndrome (SARS) during 2003, although considerably smaller in scale, resulted in 8098 cases and 774 deaths5 and is a dramatic contemporary example of the ability of viral pneumonias to rapidly disseminate and cause severe disease in human populations.

The clinical significance of measles: a review

Forty years after effective vaccines were licensed, measles continues to cause death and severe disease in children worldwide. Complications from measles can occur in almost every organ system. Pneumonia, croup, and encephalitis are common causes of death; encephalitis is the most common cause of long-term sequelae. Measles remains a common cause of blindness in developing countries. Complication rates are higher in those <5 and >20 years old, although croup and otitis media are more common in those <2 years old and encephalitis in older children and adults. Complication rates are increased by immune deficiency disorders, malnutrition, vitamin A deficiency, intense exposures to measles, and lack of previous measles vaccination. Case-fatality rates have decreased with improvements in socioeconomic status in many countries but remain high in developing countries.

Clinical features of measles in immunocompromised children

Measles is often fatal for immunocompromised hosts. Protective immunity against measles has been studied but is still not completely understood. Recently, five cases of measles were encountered in immunocompromised children. Two of these were allogeneic bone marrow transplanted cases (one common variable immunodeficiency and one severe aplastic anemia) in remission, one Wilms' tumor case in remission, one hepatoblastoma case after cytotoxic therapy at disease onset and one exaggerating hemophagocytic syndrome case with suppressed natural killer cell activity. Clinical symptoms, laboratory findings and the immunologic backgrounds of these five patients were investigated. One of the patients, an 8 year old boy with hemophagocytic syndrome, died of giant cell pneumonia which was confirmed in the section of necropsy lung specimen. Two other patients who received allogeneic bone marrow transplants were not immune to measles, despite their own and their donors' immunizations. Their clinical symptoms were rather severe but both patients recovered and have remained seropositive for as long as 13 months. This fatality from measles is the first reported in a patient with hemophagocytic syndrome. Suppressed natural killer cell activity may be a poor prognostic factor. Also, secondary immunization failure for measles can occur in bone marrow transplanted patients with rather severe clinical symptoms.

Cytotoxic drug-induced pulmonary disease in infants and children

The increased survival rate of malignant diseases due to more aggressive treatments contributes to the occurrence of drug-induced pulmonary diseases (DIPD). We reviewed, retrospectively over a 10-year period, 15 children (8 girls) who presented a DIPD. Their mean age was 9 years (range, 1 to 17 years), with an underlying malignant disease in 14 (9 leukemias). Three typical patterns have emerged from this analysis: (1) acute hypersensitivity lung disease caused by methotrexate (in 6 patients) or azathioprine (in 1 patient). This acute syndrome consisted of alveolar-interstitial infiltrate with a hypercellularity on bronchoalveolar lavage (BAL) (mean, 714,286 cells/mL; range, 180,000-2,940,000 cells/mL) and an increase of lymphocyte counts (mean, 39%; range 11-64%) with predominantly CD8-suppressor/cytotoxic lymphocytes. Inhibition of leukocyte migration or leukocyte aggregation in the presence of low drug concentrations was positive in the 5 cases tested. Lung function tests showed a restrictive pattern and the outcome of DIPD was always favorable. (2) Chronic pneumonitis/fibrosis was seen in 6 patients who received a variable association of cyclophosphamide (3 patients), bleomycin (2 patients), BCNU (2 patients), and melphalan (1 patient). Symptoms of an alveolar-interstitial pneumonitis developed progressively. BAL showed a moderate increase of total cell numbers (mean, 495,000 cells/mL; range, 150,000-900,000 cells/mL). Lung function tests showed a restrictive pattern. Despite corticosteroid treatment in 4 children, one died after bleomycin lung injury and 2 had functional lung impairment. (3) Noncardiogenic pulmonary edema occurred in 2 patients with leukemia treated with recombinant interleukin II. BAL showed hypercellularity and outcome was rapidly favorable.(ABSTRACT TRUNCATED AT 250 WORDS)

Postmortem detection of measles virus in non-neural tissues in subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis, a rare, progressive, fatal central nervous system disease of children, is caused by measles virus. Clinical signs occur months to several years after recovery from acute measles infection. It is not known where the virus persists while the disease is inapparent. Involvement of organs outside the central nervous system has rarely been documented. To search for possible peripheral reservoirs of measles virus we used in situ hybridization to probe for measles virus RNA and immunocytochemical studies to localize measles virus antigens ina variety of organs taken at autopsy from confirmed cases of subacute sclerosing panencephalitis. Seven of 9 cadavers were found to contain measles virus RNA or antigens, or both, in at least one location outside the central nervous system. These sites included lymphoid organs such as thymus, spleen, lymph nodes, and tonsil, suggesting a role for lymphocytes in disease pathogenesis. Virus was also detected in kidney, lung, and glandular tissues such as pancreas, adrenal, and pituitary. These reservoirs may provide the antigenic stimulus leading to the elevated response characteristic for subacute sclerosing panencephalitis.

Humoral immunity in measles infection: a critical factor?

Cell-mediated immunity is generally regarded as the essential factor in recovery from measles infection. In other viral infections humoral immunity has been considered a critical factor when antibody titres were correlated with outcome or when serum therapy proved protective. A review of available studies of severe-to-fatal cases of measles infection having non-neurological symptoms indicate that the antibody response is depressed in virtually all cases. The current view of immune globulin being an ineffective therapeutic agent is based on treatment of measles encephalitis; in fact, the least effect should be expected among encephalitis cases since some already have antibodies from the onset of symptoms. Larger examinations of measles with other than neurological symptoms suggest that immune globulin has a beneficial impact on the clinical course of infection. There are indications that hyperimmune globulin increases the efficacy of this form of treatment. Since measles is still a major cause of hospitalization and mortality, further studies of the therapeutic effect of specific immune globulin are warranted. From our current knowledge, both the humoral and cell-mediated immunity seem to be critical factors in recovery from measles infection.

Giant cell pneumonia in Letterer-Siwe disease

An 8 month-old girl suffered from Letter-Siwe disease since one week after birth. During the chemotherapy, giant cell pneumonia caused by measles virus infection developed and led rapidly to her death. Histopathologically, alveolar spaces were lined by multi-nucleated giant cells with intranuclear and intracytoplasmic eosinophilic inclusion bodies. Electronmicroscopical examination of the lung revealed intranuclear inclusion bodies full of rod-shaped structures characteristic to paramyxoviruses, and irregular electron-dense materials compatible with nucleocapsid protein antigens in the cytoplasm. Additionally these giant cells were observed in the salivary glands, thyroid gland, thymus and lymph nodes. The measles virus antigen was detected immunohistochemically in these giant cells in the lungs and other organs. The specific antibody of measles virus is helpful to study the pathogenesis of giant cell pneumonia.

The need for new antiviral agents

Population density and immune status, vectors and virulence of infection, nutritional status, sanitation, genetic susceptibility and medical management of cases, are important factors influencing the incidence and/or severity of virus infections. Thus, the prevalence and clinical importance of virus infections and the need for antiviral drugs differ from place to place and from time to time. National and World Health Statistics of notifications of disease give some index of the incidence of infections but not all virus infections are notifiable. Such statistics can be misleading also through failures to notify from sloth on the part of the physician or, in the absence of pathognomonic symptoms or signs, from errors in diagnosis. Any assessment of the need for new antiviral drugs should consider the availability, safety, effectiveness and cost of alternative measures, including prevention of spread of infection by control of vectors, immunization by use of viral vaccines, or treatment with existing antiviral drugs. Early start of treatment of acute virus infections with existing drugs gives the best results and, where the clinical diagnosis is uncertain, accurate rapid virus diagnosis is of paramount importance. Many virus infections are asymptomatic or of trivial importance and without sequelae. However, new or improved antiviral drugs are needed for the prevention and/or treatment of a number of significant conditions caused by viruses which are not at present adequately controlled. These include upper and lower respiratory tract infections, influenza, chronic hepatitis, gastroenteritis, infectious mononucleosis, measles, rabies, haemorrhagic fevers and warts. Furthermore, such drugs might prove of therapeutic value in the prevention or treatment of virus-associated tumours, such as hepatoma, nasopharyngeal carcinoma, Burkitt's lymphoma, Kaposi's sarcoma and possibly carcinoma of the cervix.

A fourteen-year study to identify measles antigen in urine specimens by fluorescent-antibody methods

Between 1965 and 1979 inclusive, 426 morning urine specimens from 410 patients admitted to hospital with the provisional diagnosis of measles were tested for measles antigen by fluorescent-antibody methods. One hundred and forty-two specimens (33.3 per cent) were positive. Of 74 patients who were clinically assessed not to have measles, 6/77 specimens (7.8 per cent) gave false positive results, and 71/77 (92.2 per cent) gave true negative results. Three hundred and forty-nine urine specimens were tested from 336 patients clinically judged to have had measles and 136 of these specimens (39 per cent) were positive. The positive rate was highest in a small number of specimens taken before the rash and next highest at the onset of the rash. The positive rate then fell; it rose again near the end of the first week, but the further increased positive rate after that time was associated with very small numbers of specimens. Of 12 child contacts of measles, 5/12 (41.67 per cent) had positive urine specimens and one of them developed measles two days after sampling. None of the seven patients with negative urine specimens developed measles. Measles antigen was detected in urine sediment by fluorescent-antibody tests in 39 per cent of the patients with measles studied.

The lungs in fatal measles infection in childhood: pathological, radiological and immunological correlations

Multinucleated inclusion-bearing giant cells diagnostic of measles infection were identified in the pulmonary alveoli of seven children post mortem. Two children with leukaemia and a third with thymic dysplasia had prolongaed illness without typical measles exanthemata. All showed a striking proliferation of the respiratory epithelia, with formation of peribronchiolar fibro-epithelial nodules and cystic transformation of tracheo-bronchial glands. The nodular lesions contained many giant cells and were seen radiologically as multiple slowly-enlarging pulmonary opacities, a pattern which appears to be highly characteristic of measles infection in the presence of cellular immune deficiency. Two other children showed similar proliferative lesions, but had shorter illness with exanthemata and few tissue giant cells; these differences are attributed to the late appearance of a cellular immune response in less severe immune deficiencies. Two children who had no evidence of immune deficiencies died of acute viral alveolitis, one in the pre-exanthematous phase. Acute alveolitis was characterized radiologically by the rapid development of diffuse pulmonary opacification and by variable cytological features which correlated with other evidence for the presence or absence of a cellular immune response against the virus.

Measles giant cell pneumonia in childhood leukemia in remission

A four-year old girl had acute lymphoblastic leukemia in remission with immunosupressive chemotherapy and complicated giant cell pneumonia. Investigations by light and electron microscopy and immunoperoxidase study of autopsy material disclosed measles virus nature of the penumonia, although there was no typical rash of the disease. Similar giant cells were seen in the gastric and colon mucosa, and the other of Warthin-Finkeldey type in the spleen, and lymph nodes of pulmonary hiluses. To the best of our knowledge, this is the first discription of gastric giant cells with inclusion of measles virus.

Alterations of the thymus and peripheral lymphoid tissues in fatal measles. A review of 14 autopsy cases

As a result of re-examining 14 autopsy cases of fatal measles, neither aplastic nor hypoplastic thymuses were found even in a case with giant cell pneumonia, but there were degenerative and/or necrotic changes with giant cells mostly in the thymus and less in the peripheral lymphoid organs such as spleen, lymph nodes, Peyer's patches and tonsils. This damage of the lymphoid system was associated with the occurrence of complications, particularly of giant cell pneumonia and encephalitis. The lymphoid cell damage, which might be primarily due to virulence of the infected measles virus, seemed to prolong the viremia. Involvement of viremia in the process of complication is discussed.