Pulmonary
Lesions
in Atypical
Measles
Abbot Laptook, M.D.,
Edward Wind, M.D., Michael Nussbaum, M.D., and I. RonaldShenker, M.D.
Froiii the Department ofPediatrics, Dicision ofAdolescent .‘iledicine, and the i)epartmcnt of Radio!ogij, Long
Island Jewish-Hillside Medical Center, New Hyde Park, New lark, and the State Lriiuersiti, of .Vett York at Stony Brook
ABSTRACT. Atypical measles is a well-described entity which has a high frequency of pulmonary involvement. Resolution and shrinkage of the pneumonic infiltrates into nodular mass-like lesions have been cited only once before. Three cases of atypical measles pneumonia are described which demonstrate these pulmonary nodular sequelae. In one of the cases examined a nodular residuum has now
persisted for five months. Atypical measles pneumonia should be considered as a diagnostic possibility before
invasive investigations are performed in a patient who has a pulmonary nodule. Pediatrics 62:42-46, 1978, atypical
measles, pulmonary nodules.
Atypical
measles
is a well-described
entity
in
children
and
isassociated
with
prior
administra-tion
of killed
measles
vaccine.
The
association
of
atypical
measles
with
previous
administration
of
live
measles
vaccine
has
been
reported,
but
ithas
not
been
confirmed
to be a problem.
The
illness
is
characterized
by
a
prodrome
of
fever,
cough,
headache,
myalgia,
and
abdominal
pain
followed
by
the
development
of maculopapular
rash
which
starts
on
the
extremities
and
involves
the
palms
and
soles
and
subsequently
the
trunk.The
lesions
often
become
petechial
and
vesicular.
Pulmonary
involvement
is common
in atypical
measles.
The
development
of
pulmonary
nodules
lasting
for
several
months
to
years
as
a
residuum
of
this
pulmonary
involvement
has
been
rarely
reported
in the
past.’
The
purpose
of this
article
is to report
the
cases
of three
patients
with
atypical
measles
and
pulmonary
involvement
with
pulmonary
nodules.
The
importance
of pulmonary
nodules
as
a residuum
of atypical
measles
is stressed.
CASE REPORTS
Case 1
A 10-year-old white boy was well until one week before
admission when a nonproductive cough, myalgia, and fever
to 40.0#{176}C (104#{176}F)developed. This was followed by the development of a rash starting on the extremities, including the palms and soles, and spreading to the trunk and face.
There was a history of exposure to measles in school. He was immunized at 1 year of age with a fornialin-inactivated
Edmondston B measles vaccine monthly for two doses followed by one live attenuated Edmondston B measles vaccine. Physical examination revealed a febrile boy with an
erythematous papular and papulovesicular rash on the arms,
legs, buttocks, palnis, and soles and to a lesser extent on the trunk and face. There was slight conjunctival injection and a few petechial lesions on the buccal niucosa. Vesicular breath sounds were heard bilaterally, but there was no dullness to percussion. A chest roentgenograin revealed the presence of a consolidation involving the right lower lobe without evidence of a pleural effusion (Fig. 1). Multiple blood
cultures, a Monospot test, and a test for febrile agglutinins
were all negative. Viral titers showed no evidence of measles, herpesvirus, influenza virus types A and B, .\Iycoplasma, or
adenovirus. The remainder of the hospital course was tin-eventful and the rash faded and the fever defervesced over a
three- to four-day period.
Another chest roentgenogram one month after hospitaliza-tion revealed a partial resolution of the pneumonic infiltra-tion which had undergone organization into a smaller nodular mass abutting the major fissure in the right lower lobe. A hemagglutination inhibition antibody titer to rubeola
equal to 1:25,600 was obtained, confirming the diagnosis of atypical measles. Another chest roentgenogram three months later revealed the nodular mass in the right lung field
to be unchanged in size and appearance (Fig. 2). A current
five-month follow-up film has showed no appreciable change in the mass. The patient has remained clinically well.
Case
2
A 14-year-old white girl was well until four days before admission to Long Island Jewish-Hillside Medical Center
Received October 20; revision accepted for publication December 9, 1977.
Supported by research grant 3-792 from Long Island Jewish-Hillside Medical Center.
ADDRESS FOR REPRINTS: (I.R.S.) Division of .-dolescent
FIG. 1. Hazy consolidation in right lower lobe with accentua-tion of minor fissure at onset of illness.
when fever and malaise developed. This was accompanied by a rash starting on the hands and legs, which rapidly progressed to the trunk, and complaints of a nonproductive
cough, sore throat, and photophobia. On the day before admission, a chest roentgenogram revealed pneumonia and the patient was given penicillin intramuscularly. Because of increasing respiratory distress the patient was admitted on the following day. She had received three doses of killed vaccine at 1 ‘ear of age and live Schwarz vaccine in 1965 at
2 years of age.
On admission the patient was febrile and in moderate respiratory distress. She had a fading maculopapular rash
predominantly over the trunk with some petechial lesions over the lower part of the abdomen, lower extremities, arms,
palms, and soles. She was tachypneic with shallow respira-tions and dullness to percussion at both bases posteriorly.
There were bronchial breath sounds over the left middle posterior lung field but no rales.
A chest roentgenogram revealed hazy consolidation of both the right and left lower lobes (Fig. 3). An ESR was 48
mm/hr (Wintrobe). Cold agglutinins, febrile agglutinins, a Monospot test, a tine test, and multiple blood cultures were all negative. The patient was treated with supportive thera-py, intravenous fluids, and oxygen. Over a period of one week her clinical status gradually improved. On the day
before discharge a repeat roentgenogram showed shrinkage
and organization of the infiltrates with nodular residua in the superior segments of both lower lobes resembling mass-like lesions (Fig. 4). A follow-up visit one month after discharge revealed the patient to be clinically well and asymptomatic. A chest roentgenograni revealed further shrinkage of the bilateral infiltrates but the nodular character persisted (Fig.
5).
A measles hemagglutination antibody titer at the one-month follow-tip was 1:25,600. The most recent chest roentgenogram done at a two-month follow-up visit demon-strated almost complete fading and resolution of the nodular lesions.F1G. 3. Bilateral lower lobe consolidation at onset of illness.
Fic. 2. Frontal (top) and lateral (bottom) roentgenograms three months after onset of illness. There is incomplete resolution of right lower lobe infiltrate with nodular resid-uum which is flattened where it lies against major fissure
Fl;. 4. Organization of lesions in lower lobes producing mass-like appearance two weeks after onset of illness.
Case 3
A 16-year-old white girl presented to Long Island Jewish-Hillside Medical Center with a ten-day history of fever, ill-defined joint complaints, and a transient niaculopapular rash over the extremities lasting 24 hours. There was no history of any exposure to measles. She received two doses of
measles vaccine (presumptively killed) at age 3 years in 1964.
At the time of admission she was afebrile and results of the physical examination were normal. A chest roentgenogram
(
Fig. 6) revealed a consolidation in the anterior segment of the right upper lobe. There was no hilar lymphadenopathvor pleural effusion. The ESR was 57 mm/hr (Wintrobe) while the cold agglutinin, tine test, Monospot test, and blood cultures were negative. She was discharged in good condi-tion on cephalexin (Keflex), 500 mg orally four times daily.
FIG. 5. Siiiall residual infiltrates (arrows) remaining in lower lobes six weeks after onset of illness. Lateral film (not shown
clearly localizes infiltrate to lower lobes.
A follow-tip chest roentgenogram was done three weeks
after discharge. The infiltrate revealed shrinkage and consol-idation into a nodular-like lesion in the right long periphery
(
Fig. 7). Because of this appearance, a measles hemaggluti-nation antibody titer was obtained and was found to l)egreater than or equal to 204,800. Another x-ray examination done six weeks following discharge showed further shrinkage
of the nodular lesion in the right lung field. A current 3#{189}-month follow-up film has showed no apprecial)le change in the mass.
DISCUSSION
Atypical
measles
is
a
well-recognized
entity
characterized
by high
fever,
rash,
and
pneumonia.
The
rash
differs
from
that
of
natural
measles
infection
in
its
onset,
progression,
distribution,
and
character.
It starts
on the
extremities,
spreads
in a centripetal
fashion
toward
the
trunk,
is most
dense
on
the
extremities,
and
is
composed
of
papular,
vesicular,
and
petechial
lesions.
Atypical
measles
has
a
higher
frequency
of
pulmonary
involvement
compared
to
natural
measles.
This
has
been
reported
repeatedly
since
the
first
cases
of atypical
measles
were
noted.27
The
radiologi-cal
features
of atypical
measles
pneumonia
have
been
described
as lobular
or segmental
in
distri-bution.
Pleural
effusion
is a frequent
finding
and
often
there
is enlargement
of
the
hilar
nodes.M
This
differs
from
the
characteristics
of
natural
measles
pneumonia
which
has
infiltrates
without
a
specific
pattern,
bronchopneumonic
infiltra-tion,
hilar
adenopathy,
and
rarely
pleural
changes.’
Residual
changes
in
the
lung
fields
associated
with
natural
measles
infection
are
not
14
The
patients
whose
cases
are
presented
in this
article
demonstrate
a
unique
characteristic
of
atypical
measles
pneumonia.
Resolution
of
the
pneumonic
infiltrates
occurred
by
organization
and
shrinkage
into
nodular
mass-like
lesions.
In
case
1 these
have
persisted
unchanged
in
appear-ance
five
months
after
the
initial
illness.
Young
et
al.’
in a study
of
ten
patients
with
documented
atypical
measles
pneumonia
found
eight
to have
residual
nodular
lesions
on follow-up
chest
roent-genograms.
These
have
persisted
for
varying
lengths
of
time,
some
for
as
long
as
22
months
without
appreciable
change.
It is interesting
that
the
majority
of their
cases
had
pleural
effusions
and
all
had
hilar
adenopathy
in
contrast
to
our
cases.
Of significance
is the
fact
that
the
nodular
pulmonary
residuum
led
to the
diagnosis
of
atypi-cal
measles
retrospectively
in
case
3,
and
the
findings
of
pulmonary
nodules
should
alert
the
physician
to this
possibility.
The
case
of patient
2
may
be considered
a vaccine
failure
since
she
was
immunized
with
the
live
attenuated
vaccine
but
had
an illness
with
clinical
features
and
serologic
evidence
to
support
atypical
measles.
This
has
been
well
documented
in the
past.
Vaccine
fail-ures
may
be
caused
by
poor
refrigeration
of the
vaccine
or exposure
to light.
Preexisting
blocking
antibody
acquired
passively
or by
killed
vaccine
may
have
the
same
effect.’4’7
A general
discussion
of the
differential
diagno-sis of pulmonary
nodules
is beyond
the
scope
of
this
article.
The
list
is
extensive
and
includes
developmental
lesions
such
as bronchogenic
cysts
and
sequestrations,
infectious
processes
including
granulomas
and
abscesses,
primary
and
secondary
neoplasms,
hamartomas,
and
hematomas.
The
FIG. 7. Nodular residual at site of original consolidation three weeks after onset of illness.
history,
associated
physical
findings,
and
labora-tory
data
help
eliminate
several
of these
possibil-ities.
It is important
for physicians
to be aware
of the
unique
characteristic
of
atypical
measles
pneu-monia
since
the
long
persistence
of these
pulmo-nary
nodules
could
lead
to inappropriate
invasive
diagnostic
procedures
if the
original
illness
is not
appreciated.
REFERENCES
1. Young LW, Smith DI, Glasgow LA: Pneumonia of atypical measles: Residual nodular lesions. Ant I
Roentgenol 110:439, 1970.
2. Rau LW, Schmidt R: Measles immunization with killed virus vaccine. Am I Dis Child 109:232, 1965.
3.
Ftilginiti VA, EllerJJ,
Downie AW, Kempe CH: Alteredreactivity to measles virus: Atypical measles in children previously immunized with inactivated measles virus vaccines. JAMA 202: 1075, 1967. 4. McLean DM, Kettyls GDM, Hingston
J,
.et al: Atypicalmeasles following immunization with killed measles vaccine. Can Med Assoc
I
103:743, 1970. 5. Nader PR, Horwitz MS, RousearJ:
Atypical exanthemfollowing exposure to natural measles: Eleven cases in children previously inoculated with killed vaccine.
I
Pediatr 72:22, 1968.6. Brodsky AL: Atypical measles: Severe illness in recipi-ents of killed measles vinis vaccine upon exposure to natural infection. JAMA 222:1415. 1972. 7. Welliver RC, Chery D, Holtzman E: Typical, modified
and atypical measles. Arc/i Intern Med 137:39, 1977.
8. Pneumonia in atypical measles. Br Med I 1:235, 1971. 9. Dover AS, Escobar JA, Duenas AL, Neal EC:
Pneumo-nia associated with measles. JAMA 234:612, 1975. 10. Kohn JL, Koiransky H: Successive roentgenograins of
the chest of children during measles. Ant
I
Di.s Child38:258, 1929.
reexamina-tion of chests of children from six to ten months
after measles.
Am I Dis Child 41:500, 1931.12. Kohn JL, Koiransky H: Further roentgenographic stud-ies of chests of children during measles. Am
I
DisChild 46:40, 1933.
13. De Carlo
J
Jr. Startzman HH: Roentgen study of the chest in measles. Radiology 63:849, 1954.14.
Fawcett
J,
Parry HE: Lung changes in pertussis and measles in childhood: Review of 1,894 cases. Br IRadiol 30:76, 1957.
15. Cherry JD, Feigin RD, Lobes LA, Shackelford K: Atypical measles in children previously immunized
with attenuated measles virus vaccine.
Pediatrics-50:712, 1972.
16. Plotkin SA: Failure of protection by measles vaccine. I
Pediatr 82:908, 1973.
17. Knigman 5: Present status of nieasles and rubella immunization in the United States: A medical progress report. I Pediatr 90: 1, 1977.
ACKNOWLEDGMENT
We thank Dr. S. Krugman for performing the follow-up measles antibody titers and Dr. P. Lanzkowsky for his advice in the preparation of this article.
TOWARD
CIVILIZED
BEHAVIOR
. .
.Changes
in table
manners
are
not
mere
curiosities.
On
the
contrary,
they
reflect
fundamental
shifts
in human
relationships.
The
men
who
ceased
to eat
from
the
same
dish
and
drink
from
the
same
cup
were
separated
by a new
wall
of
restraint
and
embarrassment
at
the
bodily
functions
of
others.
This
new
sense
of shame
was
visible
in many
areas.
Originally
people
spat
on
the
floor;
then
they
were
encouraged
to put
their
foot
over
the
spittle;
later
they
used
a
spittoon;
finally
even
that
symbol
of delicacy
disappeared
and
they
ceased
to
spit
in polite
society
altogether.
In the
same
way
they
progressed
from
blowing
their
noses
on their
sleeves
to using
their
left
hand,
to using
only
two
fingers,
to
adopting
a handkerchief
(Erasmus
left
only
two
forks,
but
he owned
thirty-nine
handkerchiefs).
Instead
of
sleeping
naked,
several
to
a
bed,
they
put
on
nightclothes
and
converted
bedrooms
into
private,
intimate
areas.
Nudity
became
shameful
and
an unmade
bed
was
an
embarrassing
spectacle.
Similar
inhibitions
grew
up around
the
bodily
functions.
In the
sixteenth
century
itwas
considered
dangerous
to hold
one’s
wind;
by
the
eighteenth
century
it was amajor
solecism
to
release
it in
company.
Defecating
and
urinating
became
private
activities,
screened
from
public
gaze.
Language
became
more
delicate.
Prudery
surrounded
wedding
ceremonies,
prostitution,
and
the
discussion
of
sexual
matters.
The
aggressive
impulses
were
inhibited.
To
express
pleasure
in
violence,
whether
in mutilating
one’s
opponents
in battle
or
in burning
cats
alive
(an
animal
ceremony
in sixteenth
century
Paris)
came
to be
regarded
as
“sick”
or
“infantile.”
All
these
changes
were
in the
same
direction.
They
involved
the
repression
of spontaneous
behavior,
the
distancing
of men
from
their
bodily
functions,
and
the
checking
of physical
impulses
by
self-imposed
inhibition.
In
this
way
the
courtoisie
of the
Middle
Ages
gave
way
to the
“civility”
of the
Renaissance;
and
that
in turn
developed
into
what
Europeans
in the
later
eighteenth
century
were
beginning
to think
of as “civilization.”
The
fork,
the
handkerchief,
and
the
nightdress
acquired
a
crucial
symbolic
value.
Refined
table
manners,
intense
bodily
control,
and
a high
threshold
of embarrassment
were
the
essence
of
“civilized”
behavior.
The
new
inhibitions
performed
an
essential
social
function,
distinguishing
adults
from
children,
the
upper
and
middle
classes
from
their
inferiors,
and
Western
Europeans
from
“savages.”
KEITH THOMAS
Submitted
by
Student
From Thomas K (reviewer), Elias N: The Rise of the Fork, book review. New York Times Renew