LAUSR

Dear editor, Over the last few months, Europe has witnessed an outbreak of measles mostly in adolescents and young adults. According to the last report on measles from European Centre for Disease Prevention and Control, over the first 6 months of 2017, 10,866 cases have been reported, mostly in Italy and Romania (respectively 37 and 36%), with the 86% of affected unvaccinated [1]. Though vaccination was introduced in Italian national schedule about 20 years ago, after 2007, a decreasing trend in coverage has been observed [2]. Measles vaccination is one of the most effective health interventions ever developed. Without the vaccine, five million children would die each year from measles—assuming an estimated case-fatality rate of 2–3% [3]. In adults, respiratory and neurological complications account as main causes of hospitalization in acute phase [4]. Here, we present a case of measles with severe neurological impairment in a young unvaccinated woman. On January 2017, a 32-year-old Romanian woman permanently resided in Italy presented at emergency department with acute urinary retention and limb weakness. She was febrile with maculopapular rash at neck and face (more prominent behind the ears). During the previous week, she had pharyngitis and fever, treated with clarithromycin by her general practitioner, while her 4-year-old daughter had been hospitalized for pneumonia few weeks before. The patient had no other prior relevant history. Neurological examination was suggestive of acute myelitis, showing normoreflexic tetraparesis with distal weakness, walk only with double support, loss of pain sense at both forearms and hands and below mammillary line. At admission, blood exams were unremarkable with the exception of a mild increase of GPT/GGT (respectively 3/2 times above the normal range); at spine MRI extensive hyperintensity at T2-weighted sequences was observed at anterocentral portion of the spinal cord from C4 to conus medullaris, with enhancement at C6-C7 (Fig. 1a–c); cerebrospinal fluid (CSF) examination revealed 225/mmc white cells (neutrophil/lymphocyte ratio 52/48), 115 mg/dl proteins, and normal glucose. With the suspicion of infective myelitis, empiric therapy with ceftriaxone, azithromycin, and acyclovir was started since the admission and then discontinuedwhen CSF culture and serological testing (including Treponema pallidum, HIV, Mycoplasma pneumoniae, parvovirus B19, Borrelia burgdorferi, herpetic viruses, toxoplasma, rickettsia, and QuantiFERON-TB) resulted all negative. Oligoclonal bands in CSF were absent. Due to the coexistence of fever, skin rash, pharyngitis, and myelitis, serum anti-measles antibodies were tested: on day 2, their results came and were suggestive of acute infection (IgM 1.9, n.v. 0.0–1.1; IgG > 300, n.v. 0–16 UA/ml). Retrospectively, the patient revealed that she and her daughter were both unvaccinated for measles and had recently got in touch with an affected child. To reduce inflammation at spinal cord, i.v. 8 mg dexamethasone was administered since the first day and then tapered after 2 weeks when a new spine MRI revealed a definite resolution of spinal cord inflammation (Fig. 1d–f). Brain MRI performed on day 7 was normal. After 2-month rehabilitation, the patient could walk independently; after 6 months, intermittent self-catheterization was interrupted due to improvement of bladder function. Neurological complications of measles are rare but severe and include primary measles encephalitis (PME), postinfectious encephalomyelitis (PIE), measles inclusion body encephalitis (MIBE), and subacute sclerosing panencephalitis (SSPE) [3, 4]. PME is due to the direct infection of brain byMorbillivirus in exanthema phase, with presence of infectious measles virus in CSF. Headache, seizures, ataxia, and weakness are typical neurological presentations. Brain MRI shows T2 focal * I. Colombo [email protected]