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Revista Romn de Medicin de Laborator Vol. 24, Nr.

3, Septembrie, 2016 337

Case Study

DOI: 10.1515/rrlm-2016-0028

Severe pneumococcal pneumonia following


Measles- Mumps- Rubella vaccination
Pneumonie pneumococic sever dezvoltat ca urmare
a vaccinrii Rujeol-Oreion-Rubeol

Orsolya Gl1, Mathias W. Pletz2, Edith Simona Ianoi1


1
University of Medicine and Pharmacy of Trgu Mure, Romania,
2
Center for Infectious Diseases and Infection Control Jena University Hospital, Jena Germany

Abstract
Hereby, we report a case of severe multi-lobular pneumococcal pneumonia with gangrene requiring pneumonecto-
my and accompanying septic shock that developed 1 day after a live-attenuated measles-mumps-rubella vaccina-
tion in a 58-year old kindergarten teacher.
Keywords: severe pneumococcal pneumonia, Measles- Mumps- Rubella vaccination.

Rezumat
Prezentm un caz de pneumonie pneumococic multilobular sever cu gangren i oc septic, necesitnd pneu-
monectomie care s-a dezvoltat dup o zi de la administrarea vaccinului viu-atenuat rujeola-oreion-rubeola la o
educatoare de 58 de ani.
Cuvinte cheie: pneumonie pneumococic sever,vaccinare Rujeol-Oreion-Rubeol.
Received: 06th March 2016; Accepted: 08th August 2016; Published: 16th August 2016.

is provided by the combined live attenuated


Introduction measles-mumps-rubella vaccination (MMR),
Measles is one of the most contagious viral diseas- no single vaccine against measles is currently in
es, which was a leading cause of death worldwide clinical use. MMR has a good safety profile that
several decades ago. As it is a vaccine-prevent- is rarely associated with life-threatening compli-
able infectious disease, intensive arrangements cations or adverse events. To achieve and main-
and effective immunization programmes have tain high levels of population immunity, WHO
been initiated in order to prevent measles in- developed strategies providing high vaccination
fection and to reach the global elimination of coverage with two doses of MMR vaccine (2).
the disease (1). Vaccination against measles In accordance with the European Centre for
Disease Prevention and Control (ECDC), the

* Corresponding author: Edith Simona Ianoi, University of Medicine and Pharmacy of Trgu Mure,
Str. Gh. Marinescu, Nr. 5 Trgu Mure, Romania, e-mail: ianosi_edith70@yahoo.com
338 Revista Romn de Medicin de Laborator Vol. 24, Nr. 3, Septembrie, 2016

latest German national immunization schedule personnel and international travelers 2 doses of
(August, 2013) recommends one dose of mea- MMR vaccine should be administered (3).
sles vaccine for adults aged 18 years and over Naturally acquired measles causes transient
and born from 1970 onward with no or uncertain immunosuppression leading to a temporary
vaccination history, with no vaccination history CD4 lymphocyte deficiency (4-6). In conse-
or with only one dose received during childhood. quence, pneumonia is one of the most serious
In addition, the German Standing Committee on complications associated with measles, and at
Vaccination (STIKO) stresses the importance of least 50% of measles-related pneumonias are
measles vaccination in health care personnel and due to bacterial superinfection and chronic sup-
community health workers caring for patients purative lung disease is a typical complication
with immunodeficiency disorders (www.stiko. after measles in non-vaccinated children (7-9).
de). Only one commercial type of MMR vaccine However, pneumonia after naturally acquired
is available in Germany. measles may also manifest due to direct viral
The recommendation of the Advisory Com- invasion. Another important mechanism that
mittee on Immunization Practices (ACIP) on predisposes to bacterial superinfections is that
MMR vaccination available in the United States of direct damage to the respiratory tract through
is similar to the European guides except that edema or loss of cilia by common viral patho-
persons born in 1957 or after should receive at gens, e.g. influenza, which proved to alter NK-
least 1 dose of MMR vaccine if they do not have cell response as well (10).
the evidence of immunity. For those adults who Streptococcus pneumoniae is the most fre-
might be at increased risk for exposure or trans- quent cause of community-acquired pneumonia
mission of these diseases, students, health care (CAP). Pneumococcal disease develops suc-

Intensive Care
Hospitalization Intubation
Onset of Symptoms Mechanical ventillation
Vaccination

0 1 2 3 4 5 6 7 8 9

Pneumonectomy Second-look thoracotomy Patient discharged

10 11 12 13 28 29

Figure 1. Time course of events after vaccination


Revista Romn de Medicin de Laborator Vol. 24, Nr. 3, Septembrie, 2016 339

ceeding nasopharyngeal colonization with the placed by ceftriaxone on the 3rd day (2g, od). Fur-
homologous strain (11). Several studies show ther molecular diagnostic tests found no evidence
that the highest frequency of pneumococcal col- of recent infection by other respiratory pathogens.
onization is found in young children, this risk Due to worsening respiratory insufficiency
group is thought to be responsible for horizontal and non-decreasing CRP (306.8 mg/l), ciprofloxa-
dissemination of pneumococcal strains within cin (400 mg, tid) was added on the 6th day to cover
the community (12). possible superinfection by nosocomial Gram-neg-
ative pathogens. On the same day, the patient de-
veloped severe hyponatremia (115mmol/l) re-
The clinical case quiring treatment with fludrocortison.
In June 2014, a 58-year-old female kindergarten On the 8th day, respiratory failure required
teacher underwent an MMR vaccination. invasive mechanical ventilation. A repeated
Vaccination had been recommended due to chest CT scan revealed complete consolidation
her occupation with increased risk for exposure of the right upper and middle lobes, furthermore,
to measles, rubella, or mumps. The patient and concomitant pneumothorax with pleural effu-
also her only son had never acquired measles sion were demonstrated, requiring insertion of
and had never been vaccinated before. chest tubes.
Twenty-four hours after vaccination, On the 11th day, because of the evolving
the patient developed fever and malaise. massive pleural empyema and the increasing
Because of worsening symptoms, the pa- CRP values, ceftriaxone was replaced by piper-
tient presented to the emergency room of acillin-tazobactam (13.5g per day, continuous
the local hospital on the following day and infusion) and a thoracotomy was performed re-
was immediately hospitalized because of vealing abscesses and necrosis of the entire right
worsening general health condition, fever, lung requiring total pneumectomy.
weakness, and confusion. Chest computed On the 13th day a second look thoracotomy
tomography scan confirmed the diagnosis of was performed in order to remove the intrathora-
CAP and revealed consolidation in the right cal drains and tampons and invasive mechanical
upper, middle, and lower lobes suggestive ventilation was discontinued on the 15th day. The
for pneumococcal pneumonia. According to antibiotic therapy was changed to orally admin-
the CURB severity index, the patient exhib- istered moxifloxacin 400 mg, od. The subse-
ited severe CAP with 3 (confusion, respira- quent postoperative evolution of the patient was
tory rate > 30/min, urea > 1.1 mmol/l) out of satisfactory with no further signs of infection or
4 criteria. She was immediately transferred relapse during a follow-up period of 4 weeks.
to the ICU and treatment with clarithromy- An immunodeficiency disorder was suspected
cin (500 mg, bid) and cefazolin (2 g, tid) was in the light of the fulminant and severe manifes-
initiated. After 2 days, because of worsening tation of the disease, therefore, immunological
conditions, she was transferred to the ICU of assessment was performed and preventive 10g
the University Hospital of Jena. polyvalent Immunoglobulin substitution was ad-
On admission bronchoscopy with bronchoal- ministered.
veolar lavage was performed in order to identify On the 28th day post vaccination, the patient
the etiologic pathogens. Based on the results of the was transferred to the regular ward and dis-
antibiotic susceptibility testing cefazolin was re- charged to a rehabilitation center on the 37th day.
340 Revista Romn de Medicin de Laborator Vol. 24, Nr. 3, Septembrie, 2016

Laboratory findings direct viral invasion or by direct damage to the


respiratory tract, which predisposes patients to
Microbiological analysis of the bronchial alveolar
bacterial superinfections.
lavage sample from the right lower lobe obtained
In this clinical case, a significant IgG2, IgG4
by bronchoscopy revealed Streptococcus pneu-
and IgA deficiency was detected. IgA deficien-
moniae. The isolate was completely susceptible
cy predisposes to respiratory tract infections and
to macrolides, penicillin and cephalosporines.
is associated with impaired antibody responses
The laboratory diagnosis of viral and fungal
to vaccination. Additionally, selective IgG2 and
respiratory tract infections was accomplished
4 subclass deficiency have been identified as a
through multiplex real-time reverse transcriptase
risk factor for infections by encapsulated bac-
polymerase chain reaction (RT- PCR) assay.
teria like S. pneumoniae (14). According to the
Thirteen pathogenic respiratory agents, in-
criteria of the European Society for Immuno-
cluding ten respiratory viruses: influenza viruses
deficiencies, a diagnosis of a common variable
A and B (Inf A and Inf B), respiratory syncytial
immunodeficiency (CVID) was suspected (15).
virus (RSV), parainfluenza viruses 1-4 (PIV 1-4),
However, the patient reported to have been al-
human adenovirus (HAdV), varicella zoster virus
ways in good health and had never taken anti-
(HHV-3) and cytomegalovirus (HHV-5) and three
biotics or was hospitalized for infections before
fungal species: Candida, Aspergillus, and Crypto-
the current event, despite frequent exposure to
coccus were screened using the multiplex proto-
respiratory pathogens due to her occupational
col. None of these pathogens were detected in the
activity as kindergarten teacher. Therefore, one
patients samples. Unfortunately, measles PCR or
of the criteria of the revised diagnostic defini-
cell culture was not performed in this case.
tion for probable CVID was missing (16).
Quantitative serum immunoglobulin tests
Although increasing evidence suggests that im-
were performed for the three major immuno-
munoglobulin deficiencies predispose patients
globulin classes (IgG, IgA and IgM) in order to
to invasive bacterial infections (14), it remains a
assess the humoral immunity and this revealed a
subject of debate if the patients immune deficit
significant IgG2, IgG4 and IgA-deficiency.
could have been enough to trigger the pneumo-
coccal infection even in the absence of MMR
Discussion vaccination history.
Streptococcus pneumoniae is one of the most
Measles virus (MV) has severe immunosuppres- frequent pathogen causing bacterial infection in
sive effects, which make measles patients sus- patients with measles (18), it is also proved to
ceptible to secondary bacterial or viral infections. be the major bacterial pathogen in other cases of
MV suppresses cell-mediated immunity by inhi- impaired cellular immune response, e.g. AIDS
bition of CD4+-T-cell cytokine production (4, 6). (16, 17). A recently published review summa-
The ability of MV to suppress lymphocyte pro- rized the role of impaired immune pathways in
liferation results in lymphopenia with decreased influenza virus infection, which induces suscep-
numbers of T cells and B cells in circulation tibility to secondarybacterialpneumonia (20).
(5, 12). Unfortunately, CD4 cell count was not In this case, the presence of a viral or fungal
measured during this hospitalization. However, respiratory tract coinfection was also supposed,
an absolute lymphopenia (1.22Gpt/l) was meas- but as presented earlier, the laboratory diagnosis
ured. We should also take into consideration the revealed no viral pathogen.
fact that pneumonia could also be caused by
Revista Romn de Medicin de Laborator Vol. 24, Nr. 3, Septembrie, 2016 341

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