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Measles-associated encephalopathy in children with renal transplants
A Turner1, D Jeyaratnam, F Haworth
1Guy's and St Thomas' NHS Foundation Trust, Departments of Paediatric Nephrology, Infection and Paediatric Neurology, London, UK.
Abstract:
Two children, boys of 8 and 13 years, presented with measles-associated encephalopathy several years after kidney transplantation for congenital nephrotic syndrome. In the absence of prior clinical measles, the neurological symptoms initially eluded diagnosis, but retrospective analysis of stored samples facilitated the diagnosis of measles-associated encephalopathy without recourse to biopsy of deep cerebral lesions. Each had received a single dose of measles mumps and rubella vaccine before 12 months of age. Prior vaccination, reduction of immunosuppression and treatment with intravenous immunoglobulin and ribavirin may have contributed to their survival. Persistent measles virus RNA shedding, present in one child, was not controlled by treatment with i.v. ribavirin. Two years later, both patients continue to have functioning allografts with only minimal immunosuppression. These cases illustrate the difficulty in diagnosing measles-associated encephalopathy in the immunocompromised host, even in the era of molecular diagnostics, and highlight the renewed threat of neurological disease in communities with incomplete herd immunity.
Insights
Measles-associated encephalopathy is difficult to diagnose in immunocompromised children, even with molecular tools. Early vaccination and reduced immunosuppression may aid survival in these rare cases.
Area of Science:
- Pediatric Nephrology
- Pediatric Neurology
- Infectious Diseases
Background:
- Kidney transplant recipients are at risk for opportunistic infections.
- Measles-associated encephalopathy (MAE) is a rare complication of measles infection.
- Congenital nephrotic syndrome requires long-term management, including transplantation.
Observation:
- Two pediatric kidney transplant recipients developed measles-associated encephalopathy years post-transplant.
- Neurological symptoms were initially subtle and challenging to diagnose.
- Both patients had received a single dose of measles, mumps, and rubella (MMR) vaccine prior to age one.
Findings:
- Diagnosis of MAE was confirmed via retrospective sample analysis, avoiding invasive brain biopsy.
- Measles virus RNA shedding persisted in one patient despite intravenous ribavirin treatment.
- Both patients survived and maintained functioning kidney allografts with minimal immunosuppression.
Implications:
- MAE diagnosis in immunocompromised hosts requires high clinical suspicion and advanced diagnostics.
- Incomplete herd immunity poses a renewed risk for vaccine-preventable neurological diseases.
- Management strategies involving vaccination, immunosuppression adjustment, IVIG, and ribavirin may improve outcomes.
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