What are the potential complications of measles in children, particularly those under 5 years old with weakened immune systems, such as Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) or undergoing chemotherapy?

Complications of Measles in Children

Overview of Measles Complications

Measles causes severe and potentially fatal complications in children, with the highest mortality risk occurring in infants under 5 years old, particularly those who are malnourished or immunocompromised, including children with HIV/AIDS or undergoing chemotherapy. 1, 2

Common Complications by Frequency

Most Frequent Complications

• Diarrhea is the most common complication of measles 1, 3
• Middle ear infection (otitis media) follows as the second most common complication 1, 3
• Bronchopneumonia represents a major cause of morbidity and is the leading cause of measles-related death 1, 2

Severe Neurological Complications

• Acute encephalitis occurs in approximately 1 per 1,000 measles cases and can result in permanent brain damage 1, 3, 4
• Subacute sclerosing panencephalitis (SSPE) is a rare but invariably fatal late complication that appears years after the initial infection, even in immunologically normal individuals 1, 2, 4

Mortality Risk

• Death occurs in 1-2 per 1,000 reported measles cases in the United States, primarily from pneumonia and acute encephalitis 1, 3, 2
• The case fatality rate can reach as high as 25% in developing countries 1

High-Risk Populations with Increased Complications

Age-Related Risk Factors

• Infants and children under 5 years face the highest mortality risk compared to older children and adolescents 1, 2
• Adults experience higher complication rates than school-aged children 1

Immunocompromised Children

• Children with HIV/AIDS are at increased risk for severe complications if infected with measles 5
• HIV-infected children may develop severe, prolonged infection, sometimes without the typical measles rash 1
• Children undergoing chemotherapy or with leukemia/lymphoma face higher risk of severe and prolonged infection 2
• Children on high-dose corticosteroids (≥20 mg/day prednisone for >2 weeks) are considered immunosuppressed and at higher risk 1

Nutritional Status

• Malnourished children have significantly increased mortality risk, particularly in developing countries 1, 2, 6
• In one intensive care study, 11 of 15 children requiring mechanical ventilation for measles complications were malnourished 6

Respiratory Complications in Detail

Severe Pneumonia and ARDS

• All children requiring intensive care for measles needed mechanical ventilation for pneumonia causing severe respiratory distress 6
• Seven of 15 critically ill children developed adult respiratory distress syndrome (ARDS) 6
• Spontaneous pneumothorax occurred in three patients on admission and four during treatment 6
• Empyema developed in two patients 6

Additional Respiratory Sequelae

• Chronic lung disease can develop as a long-term complication 6
• Fibrosing alveolitis occurred in one patient during treatment 6

Systemic and Multi-Organ Complications

Hematologic Complications

• Hypocalcemia occurred in 11 of 15 critically ill children 6
• Thrombocytopenia developed in eight of 15 patients 6
• Coagulopathy occurred in seven patients 6

Infectious Complications

• Secondary bacterial sepsis is an early and prominent complication requiring early antibiotic treatment 6
• Sepsis occurred in five of 15 critically ill patients on admission 6
• Nosocomial sepsis developed in one patient during treatment 6

Cardiovascular and Neurological

• Shock occurred in three patients 6
• Encephalopathy developed in seven of 15 critically ill children 6
• Brain infarct occurred in one patient 6
• Thrombus formation developed in three patients 6
• Hemiplegia resulted as a long-term sequela in one patient 6

Pregnancy-Related Complications

Pregnant women infected with measles experience increased rates of:

• Premature labor 1, 3, 2
• Spontaneous abortion 1, 3, 2
• Low birth weight infants 1, 3, 2
• Increased maternal and fetal mortality risk 2

Management to Reduce Complications

Vitamin A Supplementation

The American Academy of Pediatrics recommends vitamin A supplementation for all children with clinical measles to reduce mortality risk 1, 2:

• Children under 12 months: 100,000 IU orally 1
• Children over 12 months: 200,000 IU orally 1
• Repeat dose on day 2 for children with complicated measles 1
• Additional dose 1-4 weeks later for those with vitamin A deficiency eye symptoms 1

Supportive Care

• Antibiotics should be instituted early for secondary bacterial infections, particularly pneumonia 1, 6
• Oral rehydration therapy for diarrhea 1, 2
• For mechanically ventilated patients, use the lowest possible inspiratory pressure and fraction of inspired oxygen to prevent ARDS complications 6

Critical Clinical Pitfall

Even patients who experience uncomplicated acute measles have a small but real risk for developing SSPE years after their infection, making prevention through vaccination paramount 7. This devastating neurologic illness can occur despite recovery from the initial measles infection 1, 4, 7.