Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 29  |  Issue : 1  |  Page : 174-176

Air leak syndrome complicating measles: report of two cases


Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria

Date of Submission08-Mar-2014
Date of Acceptance20-May-2014
Date of Web Publication18-Mar-2016

Correspondence Address:
Ibrahim Aliyu
FMCPaed, Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, 700001 Kano
Nigeria
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.179010

Rights and Permissions
  Abstract 

Measles still remains a public health concern despite an understanding of its immunology and availability of potent vaccines. The problem of maintenance of cold chain and vaccine acceptance has decreased the level of herd immunity in most Nigerian communities; therefore, yearly outbreaks are not surprising. Among the complications of measles in the respiratory system are subcutaneous emphysema, pneumothorax, and pneumomediastinum, which may be fatal in some cases. Therefore, cases of air leak seen during a recent measles outbreak are reported.

Keywords: Air leak syndrome, measles, pneumomediastinum, pneumothorax, subcutaneous emphysema


How to cite this article:
Aliyu I. Air leak syndrome complicating measles: report of two cases. Menoufia Med J 2016;29:174-6

How to cite this URL:
Aliyu I. Air leak syndrome complicating measles: report of two cases. Menoufia Med J [serial online] 2016 [cited 2019 Sep 21];29:174-6. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/174/179010


  Introduction Top


Measles still remains a major health scourge in the tropics and subtropics despite the availability of vaccines; epidemics occur frequently in northern Nigeria, often occurring in the late half of the dry season and terminating with the onset of the rainy season, which is similar to that reported by Morley and Woodland [1]. Cases are still being recorded in patients who were vaccinated; the reasons put forward for this include vaccine failure because of poor maintenance of the cold chain, decreasing herd immunity, and possibility of emergence of wild strains [2]. The measles virus affects a wide range of organs including the respiratory system, resulting in complications such as croup, bronchopneumonia, pneumothorax, pneumomediastinum, pneumopericardium, and subcutaneous emphysema [3]. Subcutaneous emphysema in measles is a rare event; Swar et al. [4] reported 11 cases in their review of 172 patients who had measles. Although most cases of subcutaneous emphysema are not life threatening, however massive subcutaneous emphysema may cause respiratory distress and this may be associated with tension pneumothorax resulting in death; hence, an overview of cases of air leak syndrome seen in children with measles during a recent outbreak in our institution is reported.


  Case reports Top


Cases of air leak syndrome were reviewed in the 2013 measles outbreak and only two patients out of 176 cases were diagnosed with subcutaneous emphysema and pneumomediastinum.

Consent

Consents were obtained from the care givers for the use of these pictures.

Case 1

A 2-year-old girl diagnosed with measles presented with fever and neck swelling 5 days after the appearance of body rash. She was not vaccinated against measles and was the fourth child in a monogamous family setting of five children; the other children had also not been immunized. The swelling became progressive, involving the face, eyes [Figure 1], upper limbs, and vulva, and crepitus was present. There was difficulty in breathing with intercostal recessions and bilateral crepitations. Oxygen saturation in room air was 90%. Her anthropometry was normal for age. The chest radiograph showed a pneumomediastinum and air in the soft tissue of the axillary area [Figure 2]. She was managed for measles with bronchopneumonia and subcutaneous emphysema with pneumomediastinum. She received antibiotics (ampicillin/cloxacillin); supplemental oxygen therapy increased the oxygen saturation to 100%. She improved progressively [Figure 3] and was discharged on the 14th day of admission.
Figure 1: Extensive subcutaneous emphysema involving the face and chest wall.

Click here to view
Figure 2: Chest radiograph showing pneumomediastinum.

Click here to view
Figure 3: Complete resolution of subcutaneous emphysema.

Click here to view


Case 2

A 3-year-old boy presented with fever and difficulty in breathing a week after measles rash, which worsened with the appearance of neck, chest, and facial swellings [Figure 4]; the swellings also had a crepitus feel. He was also not vaccinated against measles and had two siblings with measles. On chest examination, he was tachypneic, with a respiratory rate of 70/min, intercostal recession, and flaring of the ala nasi with bilateral crepitations; oxygen saturation in room air was 89%. Chest radiography indicated pneumomediastinum with evidence of air in the surrounding axillary soft tissue. He was managed for measles with bronchopneumonia and subcutaneous emphysema with pneumomediastinum. He was also placed on a combination of ampicillin and cloxacillin; supplemental oxygen increased the oxygen saturation to 96%, with significant improvement (the swellings subsided and difficulty in breathing resolved) by the seventh day of admission. However, 2 days later, the neck swelling reoccurred, with recurrence of difficulty in breathing and worsening oxygen desaturation to 85%. The patient still improved with conservative management and was discharged home 2 weeks later.
Figure 4: Subcutaneous emphysema also affecting the face and eyelids.

Click here to view



  Discussion Top


Subcutaneous emphysema, pneumothorax, and pneumomediastinum are components of air leak syndrome that may result from rupture of the alveoli or respiratory airway. Esophagus rupture and dental extraction may also cause pneumomediastinum and subcutaneous emphysema, respectively [5,6]; in measles, the pathogenesis of mediastinal emphysema follows the principle of the pressure gradient theory (Macklin phenomenon) [7]. The pressure gradient generated between the alveoli and the perivascular sheaths causes the alveoli to rupture and allows air to leak into the interstitium of the lung and mediastinum. Common causes of such gradient include overinflation of the alveoli because of airway obstruction from secretions or enlarged lymph nodes. Furthermore, lowering of the vascular pressure in the hypovolemic state can also lower the perivascular sheath pressure, initiating this pressure head. During severe coughing in measles, forced expiratory effort obstructs the systemic venous return, increasing intrapulmonary pressure, which results in alveoli rupture. The role of secondary bacterial infection - especially in malnourished children - which may further weaken the alveolar walls, resulting in pneumatocele, cannot be overemphasized [8]. Although both cases were not malnourished and cough was never a predominant complaint in them, the severity of infection may be the most probable risk factor for alveoli rupture. Nevertheless, all these mechanisms may be operational concurrently and air tracks along the perivascular sheath into the mediastinum and other potential spaces spreading superiorly to the thoracic inlet at the root of the neck into the subcutaneous space; because of the connection among the facial planes of the thorax, neck, face, limbs, and abdomen including the perineum [9,10], the spread may be extensive as was observed in the first case. However, subcutaneous emphysema may also occur following pneumothorax; this results from a tear on the parietal pleura, with air leaking into the subcutaneous space. Therefore, the presence of subcutaneous emphysema should necessitate a closer monitoring and a thorough review of both the clinical details and the chest radiographs.

Only two cases of subcutaneous emphysema were recorded out of 176 cases of measles seen, which was lower than that reported by Swar et al. [4] (1.1 vs. 5.9%).

The cases improved markedly with conservative management. Oxygen (100%) plays a significant role in the management of air leak syndromes; oxygen displaces air in the potential spaces with replacement of air with oxygen, which is subsequently reabsorbed into circulation. Other modalities of management include subcutaneous catheterization (drain), chest tube insertion, and blow holes [11].

Therefore air leaks in measles require constant review and close monitoring because re-occurrence of an air leak may occur even after an initial resolution.


  Conclusion Top


Air leak syndrome in measles is a rare event. Only two cases out of 176 were recorded. Although subcutaneous emphysema may be benign and can usually be managed conservatively, it may be a harbinger of severe disease; therefore, patients should be monitored closely.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Morley D, Woodland M. Measles in Nigerian children: a study of the disease in West Africa, and its manifestations in England and other countries during different epochs. J Hyg (Lond) 1963; 61 :115-134.  Back to cited text no. 1
    
2.
Nkowane BM, Bart SW, Orenstein WA, Baltier M. Measles outbreak in a vaccinated school population: epidemiology, chains of transmission and the role of vaccine failures. Am J Public Health 1987; 77 :434-438.  Back to cited text no. 2
    
3.
Moons P, Thallinger M. High incidence of subcutaneous emphysema in children in a Somali refugee camp during measles outbreak. Pediatr Infect Dis J 2014;33:96-8.  Back to cited text no. 3
    
4.
Swar MO, Srikrishna BV, Khogali FM. Post-measles pneumomediastinum and subcutaneous emphysema in malnourished children. Afr J Med Sci 2002; 31 :259-261.  Back to cited text no. 4
    
5.
Mackler SA. Spontaneous rupture of the esophagus: an experimental and clinical study. Surg Gynecol Obstet 1952; 95 :345-356.  Back to cited text no. 5
    
6.
Søreide A, Viste A. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 h. Scand J Trauma Resusc Emerg Med 2011; 19 :66.  Back to cited text no. 6
    
7.
Al-Mufarrej F, Badar J, Gharagozloo F, Tempesta B, Eric Strother E, Margolis M. Spontaneous pneumomediastinum: diagnostic and therapeutic interventions. J Cardiothorac Surg 2008; 3 :59.  Back to cited text no. 7
    
8.
Hazouard E, Koninck JC, Attucci S, Fauchier-Rolland F, Brunereau L, Diot P. Pneumorachis and pneumomediastinum caused by repeated Müller′s maneuvers: complications of marijuana smoking. Ann Emerg Med 2001; 38 :694-697.  Back to cited text no. 8
    
9.
Lantsberg L, Rosenzweig V. Pneumomediastinum causing pneumoperitoneum. Chest 1992; 101 :1176.  Back to cited text no. 9
    
10.
Sekiya K, Hojyo T, Yamada H, Toyama K, Ryo H, Kimura K, et al. Pneumoperitoneum recurring concomitantly with asthmatic exacerbation. Intern Med 2008; 47 :47-49.  Back to cited text no. 10
    
11.
Herlan DB, Landreneau RJ, Ferson PF. Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular ′blowholes′. Chest 1992; 102 :503-505.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case reports
Discussion
Conclusion
Acknowledgements
References
Article Figures

 Article Access Statistics
    Viewed905    
    Printed9    
    Emailed0    
    PDF Downloaded56    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]