To the Editors: Isolation of measles virus has typically been from respiratory, blood or urine specimens, but identification from the skin has not been documented. We describe the first known case of measles vaccine-associated disease in a DiGeorge patient on tumor necrosis factor inhibitor therapy in which genotype A Edmonston vaccine strain virus was identified from skin scrapings of the patient’s rash. A 12-year-old boy was admitted to our hospital with a 2-day history of tactile fevers, sore throat, rash and conjunctivitis. Ten days earlier, he had inadvertently received the measles, mumps, rubella and varicella vaccine during a well-child visit. His past medical history was remarkable for DiGeorge syndrome, repaired Tetralogy of Fallot and juvenile idiopathic arthritis diagnosed at 15 months of age, which had been controlled for the past 5 years with weekly injections of the tumor necrosis factor inhibitor etanercept. With the exception of live virus vaccines, he was otherwise up-to-date with his immunizations. He had recently undergone immune evaluation with a lymphocyte count of 1100 × 109 cells/L, of which the lymphocyte subsets were normal. The lymphocyte mitogen and antigen studies included low-normal responses to Candida and phytohemagglutinin and normal responses to tetanus, concanavalin A and pokeweed mitogen. Antibody titers to prior inactivated vaccines were normal. After he developed the tactile fevers, his mother held further doses of etanercept, and he was directly admitted to the hospital. On admission, he was afebrile and appeared well. His examination was remarkable for mild conjunctivitis, palatal petechiae with posterior pharyngeal erythema and a blanching morbilliform rash that was present behind the ears, on the face, neck, back, chest and limbs. Mild post auricular cervical lymphadenopathy was present. There were no Koplik spots or vesicular lesions. Due to the possibility of an atypical varicella rash in a patient on a biologic immunomodulatory medication, intravenous acyclovir was initiated and the Minnesota Department of Health was notified. Scrapings of the rash were sent to evaluate for varicella zoster virus, and a urine sample and a buccal swab were collected for evaluation of measles virus. Nucleic acids were isolated from the urine and skin samples using the Qiagen Viral RNA Mini Kit (Qiagen, Germantown, MD). Detection of measles virus was attained with a real-time TaqMan reverse transcription polymerase chain reaction targeting the nucleoprotein (N) gene.1 Genotyping was determined following World Health Organization-recommended sequencing, which were aligned with CDC-designated reference sequences using MEGA5 software.2 Both urine and skin samples were positive in triplicate for measles virus by reverse transcription polymerase chain reaction with 100% matched identity to each other and phylogenetically clustered as genotype A with Edmonston reference strain (AF266288). The buccal swab was inconclusive based on extraction control failure. Although excretion of measles virus in his urine enabled detection and sequencing of the virus as a measles vaccine strain, the diagnosis of vaccine-associated disease was determined from the skin scrapings.3 Measles virus is present in the skin rash during illness;4 however, to our knowledge, this is the first reported measles vaccine case in which the vaccine strain was detected and genotyped from the skin rash. Pui-Ying Iroh Tam, MD Benjamin R. Hanisch, MD Division of Pediatric Infectious Diseases, University of Minnesota Amplatz Children’s Hospital Minneapolis, MN Kate Klammer, BS Aaron S. DeVries, MD, MPH Minnesota Department of Health St. Paul, MN
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Feb 1, 2023
Open Access
Rabia Agha + 1