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Vaccine-Associated Measles Pneumonitis in an Adult with AIDS

Jonathan B. Angel, MD; Pramila Walpita, PhD; Robert A. Lerch, PhD; Mohinderjit S. Sidhu, PhD; Malthi Masurekar, PhD; Ronald A. DeLellis, MD; James T. Noble, MD; David R. Syndman, MD; and Stephen A. Udem, MD, PhD
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From Tufts University School of Medicine and New England Medical Center, Boston, Massachusetts; New Jersey Medical School, Newark, New Jersey; and Wyeth-Lederle Vaccines & Pediatrics, Pearl River, New York. Grant Support: In part by National Institutes of Health grants AI 20532, 2 SO7 RR05393, and AI 35286. Requests for Reprints: Stephen A. Udem, MD, PhD, Wyeth-Lederle Vaccines & Pediatrics, 401 North Middletown Road, Pearl River, NY 10965. Current Author Addresses: Drs. Angel, Noble, DeLellis, and Syndman: Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts University School of Medicine, 750 Washington Street, Boston, MA 02111.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(2):104-106. doi:10.7326/0003-4819-129-2-199807150-00007
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The United States last encountered a measles epidemic in the late 1980s, a time when HIV infection was rapidly penetrating urban centers. The coincidence of these epidemics prompted reappraisal of the long-standing proscription against the use of live-virus vaccine in immunocompromised patients. Recognizing the severity of measles infection, particularly in patients with cell-mediated immune dysfunction [15], the Advisory Committee on Immunization Practices (ACIP) revised its measles vaccination guidelines in 1988. They began to recommend that 12- to 15-month-old children with asymptomatic HIV infection be vaccinated and that vaccination be considered for symptomatic HIV-infected children [1]. Many HIV-infected children have since been safely immunized with live, attenuated measles vaccine [57], causing the ACIP to expand the measles immunization indication to include all persons infected with HIV, including adults, when immunization is medically warranted [1].

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Figure 1.
High-power view of lung biopsy tissue showing nodular areas of acute and chronic inflammation with regions of necrosis and fibrosis.

Multinucleated giant cells are present, some of which contain both nuclear inclusions (thin arrows) and cytoplasmic inclusions (broad arrow). (Hematoxylin-eosin; original magnification, x500.).

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Figure 2.
Nucleic acid and amino acid differences between Moraten vaccine virus and the patient's measles virus isolate.[8]

The complete genomic sequences of both viruses were determined. Total RNA was extracted from the patient's lung biopsy material, from tissue culture cells in which the patient's virus isolate was propagated, and from the commercially available Moraten vaccine virus (Attenuvax, Merck, Sharpe, & Dohme, West Point, Pennsylvania) by using TRIzol LS reagent (Life Technologies, Grand Island, New York) according to the manufacturer's protocol. The RNA was reverse transcribed to complementary DNA by using random hexamers and Murine Moloney Leukemia Virus Reverse Transcriptase (Perkin-Elmer Cetus RT-PCR kit reagents, Perkin-Elmer Cetus, Branchburg, New Jersey). The complementary DNA was then amplified by polymerase chain reaction (PCR) to create overlapping fragments that spanned the entire 15 894 nucleotide-long measles genome by using measles virus-specific oligodeoxynucleotide primer pairs whose design was based on the known Edmonston measles virus sequence . The PCR products were directly sequenced, without cloning, to obtain a consensus sequence by the dideoxy terminator cycle-sequencing method (ABI PRISM 377 sequencer and the ABI PRISM sequencing kit; Perkin-Elmer Cetus, Foster City, California). Both strands of the DNA were sequenced to eliminate possible ambiguities. The only two differences, out of the total 15 894 bases determined for each viral genome, are shown. The open-reading frames (boxes) coding for the N (nucleocapsid), P (phosphoprotein polymerase cofactor), M (matrix), F (fusion), H (hemagglutinen), and L (polymerase) proteins and the leader, trailer, and intercistronic regions (lines) are delineated in the measles virus genome (negative sense RNA) shown. All distances are proportional to their actual size within the genome. Arrows indicate the position of the nucleotide differences between the genome of the patient's measles virus and that of the Moraten vaccine virus. The nucleotide positions are given in reference to the genomic position (out of 15 894 bases total). The amino acid positions are based on the coding potential of the H (618 aa) and L (2183 aa) open-reading frames.

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