A Rare and Forgotten Complication of Measles: A Case Report of Subcutaneous Emphysema and Pneumomediastinum and Literature Review

To the Editors: After reading with excitement the article by Hester et al1 reporting the complications of measles in children, we wanted to report this rare complication that we encountered. Measles, which caused the death of millions of people in the prevaccination era, poses a significant risk of mortality and morbidity, especially in children under 5 years of age.2 Complications like diarrhea, pneumonia and otitis may occur in approximately 30%.2 Extra-alveolar air leak conditions are also well described but have been reported rarely in the literature. A 12-year-old male patient presented with a fever of 40.5 °C, rash, weakness and cough for 3 days. The patient had none of childhood vaccinations. In addition to maculopapular rash spreading all over the body, there were crepitations on the front, side and back of the neck and chest. Bilateral widespread crepitant rales upon auscultation. The radiography of the patient revealed widespread subcutaneous emphysema and pneumomediastinum with interstitial involvement in the bilateral lungs. The patient was admitted to the pediatric intensive care unit, was observed with noninvasive respiratory support for 3 days. A positive Ig M and polymerase chain reaction test confirmed measles. Ceftriaxone and vitamin A support were started. Subcutaneous emphysema was monitored with daily chest radiographs and completely resolved after 13 days. The patient was discharged without sequelae (Fig. 1).FIGURE 1.: Radiographs of application day, 5th day, and 13th day, respectively.Measles remains a serious infectious disease threat in areas where vaccination coverage is low. The most reported cause of measles-related deaths is pneumonia. Extra-alveolar air leakage cases are rare and frightening complications, and the first pediatric case in the literature was a 7-year-old girl reported in 1965. In a study by Amin et al3 in which 2044 children diagnosed with measles were evaluated, the frequency of subcutaneous emphysema was reported as 1.9%. In a study examining 3-year measles cases in South Africa, the incidence was determined as 0.59%.4 In the measles epidemic observed in a migrant camp in Ethiopia in 2014, a total of 237 patients were monitored, and the incidence of subcutaneous emphysema was calculated as 3.8% in general and 15.4% among patients under 5 years of age.5 Complications of extra-alveolar air leakage have been explained by increased intrapulmonary pressure in the consolidated lung with coughing, separations in the connective tissue with increased fragility due to inflammation, and air leakage into the extra-alveolar space.5 The extra-alveolar air leak seen in our patient was present at the time of admission. It is known that it can develop at any stage of the disease, including the convalescent period.5 Fatality rates reported during follow-up were reported as 50% by Yalaburgi,4 44% by Moons5 5.8%. Our patient was discharged without sequelae after empirical antibiotic therapy and vitamin A support, as well as respiratory and general support treatments. It is known that measles-related mortality and morbidity can be reduced with vaccination, but in today’s conditions, due to the increasing number of unplanned migrations and antivaccine individuals, immunization policies need to be planned more carefully and followed strictly.