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Brazilian Journal of Infectious Diseases

Print version ISSN 1413-8670

Braz J Infect Dis vol.16 no.3 Salvador May/June 2012

https://doi.org/10.1590/S1413-86702012000300019 

LETTER TO THE EDITOR

 

Positive measles serology and new onset of type 1 diabetes presented with bilateral facial paralysis: a case report

 

 

Eda Demir OnalI,*; Burcak PolatI; Fevzi BalkanI; Gulfem KayaI; Reyhan ErsoyI; Bekir ÇakırI; Orhan DenizII

IYıldırım Beyazıt University Medical School Ataturk Teaching and Research Hospital, Department of Endocrinology, Bilkent, Ankara, Turkey
IIYıldırım Beyazıt University Medical School Ataturk Teaching and Research Hospital, Department of Neurology, Bilkent, Ankara, Turkey

 

 

Dear Editor,

A previously healthy 28-year-old woman had suffered from fever, nausea, vomiting, and generalized fatigue for one day before being transferred to this teaching hospital's emergency department in a confused state. Physical findings on admission were height of 150 cm and body weight of 88 kg, with a body mass index of 39 kg/m2. She had a fever of 38ºC. Laboratory data on admission are shown in Table 1. Her plasma glucose and HbA1c levels were 421 mg/dL and 9.2 (normal range 4.3-5.7%), respectively. Serum test for glutamic acid decarboxylase antibody (AntiGAD) was 3 U/mL (positive if > 1 U/mL). The serum C-peptide level was 0.378 ng/dL (normal if > 1 ng/dL). A diagnosis of type 1 diabetes mellitus complicated by ketoacidosis was made based on the considerably decreased serum C-peptide level, antiGAD positivity, ketonuria, and metabolic acidosis (Table 1). She was treated with an intravenous infusion of saline and insulin, and eventually switched to intensive insulin therapy four times a day. On the second day of hospitalization she developed weakness on both sides of her face. On physical examination, there was bilateral facial nerve paralysis. An electroneuromyography demonstrated bilateral axonal neuropathy of the facial nerves and confirmed the diagnosis. A serological test for several viral antibodies was performed. The results revealed significant elevation of the measles IgM and IgG titers, but no abnormal results were shown in any of the other serological tests (Table 2). One week later, the patient's facial weakness had improved spontaneously with no residual weakness.

 

 

 

 

Measles virus infections generally occur in childhood, but infections in adolescence and adulthood can lead to complications. Pneumonia, hepatobiliary disease, encephalitis, acute renal failure, and type 1 diabetes (DM1) are among the various systemic disorders which have been associated with measles, with varying strengths of association.1-4 Data on DM1 originates from the Swedish Childhood Diabetes Study, which showed a significantly higher rate of children who developed diabetes among those not vaccinated against measles. The authors hypothesized that measles vaccine could have a protective effect, or that measles infection could be a diabetogenic agent.4 But the association between measles and DM1 is still unclear.

The differential diagnosis of the causes for bilateral facial paralysis covers a wide field, including genetic, infectious, traumatic, neoplastic, metabolic, neurological, vascular, iatrogenic, and idiopathic etiologies. Measles is not among the well-documented infectious etiologies, but three adult patients with acute renal failure and bilateral facial paralysis have been reported.5 In these patients, facial paralysis was the first neurologic sign, and then bulbar and respiratory weakness developed. Two of them died because of septicemia, and the only patient who survived had total deafness, blindness, and distal wasting. None of the patients had maculopapular rash.

The present patient could not give a reliable history and it is not possible to know whether she was vaccinated. However, she came from a rural area where compliance with the vaccination schedule was low. It is probable that she had an atypical presentation of measles, as expected in adults, because of fever and positive measles IgG and IgM antibodies. This case is interesting due to coexistence of bilateral facial paralysis, new onset of DM1, and positive measles serology. There is not a similar case in the literature. Although there are limitations with respect to the true causal relationship between measles and these two manifestations, this clinical picture should be kept in mind as a possible atypical presentation of measles infection in adults.

 

Conflict of interest

All authors declare to have no conflict of interest.

 

REFERENCES

1. Yasunaga H, Shi Y, Takeuchi M, et al. Measles-related hospitalizations and complications in Japan, 2007-2008. Intern Med. 2010;49:1965-70.         [ Links ]

2. R Khatib, M Siddique, M Abbass. Measles associated hepatobilliary disease, an overview. Infection. 1993;21:112-4.         [ Links ]

3. CY Lin, HC Hsu. Measles and acute glomeulonephritis. Pediatrics. 1983;71:398-401.         [ Links ]

4. Blom L, Nystrom L, Dahlquist G. The Swedish Childhood Diabetes Study: vaccinations and infections as risk determinants for diabetes in childhood. Diabetologia. 1991;34:176-81.         [ Links ]

5. Wairagkar NS, Gandhi BV, Katrak SM, et al. Acute renal failure with neurological involvement in adults associated with measles virus isolation. Lancet. 1999;18:992-95.         [ Links ]

 

 

Received 7 November 2011
Accepted 11 November 2011

 

 

* Corresponding author. Ceyhun Atuf Kansu Cad Ehl-i Beyt Mah 1268. Sok 10/6 TR-06520, Balgat, Çankaya, Ankara, Turkey. E-mail address: dredademir@gmail.com

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