|Year : 2016 | Volume
| 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 Submission||08-Mar-2014|
|Date of Acceptance||20-May-2014|
|Date of Web Publication||18-Mar-2016|
FMCPaed, Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, 700001 Kano
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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 . 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 . 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 . Subcutaneous emphysema in measles is a rare event; Swar et al.  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|| |
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.
Consents were obtained from the care givers for the use of these pictures.
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.|
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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.
| Discussion|| |
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) . 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 . 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.  (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 .
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|| |
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|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]