Abstract

Subacute sclerosing panencephalitis (SSPE) occurs in adolescence. The measles vaccine in time can prevent measles and in turn SSPE. The purpose of this case report is to show importance of timely measles vaccine.

Introduction

The incidence of measles is gradually decreasing as vaccine awareness and vaccine coverage is increasing. A lot of the credit goes to the medical community. However, periodic outbreaks of measles do still occur in the community even today. Such epidemics commonly affect children who are not vaccinated for various reasons. Either they have not taken any vaccine at all or have missed the measles vaccine date.

Alternatively, some children may have taken the measles vaccine at 9 months but may have never been given the MMR vaccine at 15 months. The immediate harm that measles can cause may be known to parents but the long term havoc that the disease can cause is known only to the medical community. This case report of an adolescent with subacute sclerosing panencephalitis (SSPE) strongly reinforces the need to administer the vaccine strictly at 9 months and the MMR religiously at 15 months to prevent measles at any cost and avoid the disaster of SSPE later on.

Case Report

A 16 year old male was brought with altered behaviour since 1 month, intermittent jerks since 1 week, impaired sensorium since 2 days and frank tonic clonic convulsions since 1 day. On hospitalization, the child needed intravenous diazepam for seizure control after which intravenous mannitol lead to some improvement of sensorium. The adolescent revealed emotional lability with choreoathetosis and intermittent myoclonic seizures.

Apart from various other possibilities such as viral encephalitis, Wilson’s disease and other neurodegenerative disorders, a possibility of SSPE was entertained in view of the history of measles in the first two years of life. An electroencephalogram showed a classical periodic burst suppression pattern every 3-8 seconds of high voltage sharp slow waves followed by flat background strongly suggestive of SSPE. The cerebrospinal fluid antimeasles antibody titres were positive confirming the diagnosis of SSPE. The prognosis was explained to the parents and the child was discharged on anticonvulsants.

Discussion

SSPE is a chronic encephalitis caused by persistent measles virus infection of the central nervous system. Though uncommon in the western world due to excellent vaccine coverage and hence the rarity of measles, the disease still occurs occasionally in our country. It typically occurs 5-12 years after measles. Once the disease occurs, the course is typically downhill with emotional lability, myoclonic jerks, involuntary movements, dementia, stupor and coma. Though some therapies are experimental, most patients show little improvement with any kind of therapy.¹ Hence the emphasis must be on prevention.

The importance of timely measles vaccination is sometimes lost in the maze of many other vaccinations because the gap between the third dose of DPT at 3.5 months and the measles vaccine at 9 months, is long. As a result a break may occur in the vaccination schedule.

Also, during epidemics, we as doctors do not need to stick to the 9 month recommendation and the measles vaccine can be given anytime between 6 and 9 months for early immunity and to prevent measles at any cost.²

Furthermore, use of the MMR vaccine must be made mandatory. It is relatively affordable vaccine with many advantages including boosting of the 9 months measles vaccine immunity as well as protection against mumps and rubella. The MMR vaccine is especially important in the Indian setup since the measles vaccine is given earlier in India as compared to anywhere else in the world for early immunity. However, the early vaccine may also not produce full immunity against measles, which must be boosted by MMR at 15 months.

References

1. Maldonando Y. Measles. In: Behrman RE, Kliegman RM, Jenson HB editors. Nelson Textbook of Pediatrics. Philadelphia: Saunders, 2004 : 1030-31.
2. Shah RC, Shah NK, Kukreja S. IAP Guide Book on Immunization. 4th edn., 2007 : 21-22.

*Associate Professor, **Resident, Department of Ophthalmology, T.N.M.C and B.Y.L. Nair Hospital, Mumbai - 400 008.