Department of Immunology, St Thomas' Hospital, London, UK
Sir,
The mumps, measles, and rubella (MMR) vaccination has been the subject of controversy in recent years, particularly with respect to the proposed associations with autism and Crohn's disease [1]. Recent reports, however, have found no evidence to support such associations [2]. Despite this, one result of the report by Wakefield et al. [2] has been to adversely affect uptake of the MMR vaccine in the UK.
Case
We report a 22-year-old Indian male who developed diarrhoea-negative haemolytic uraemic syndrome (HUS) after receiving the MMR vaccination in India as part of the requirements for overseas travel. Renal biopsy revealed virtually complete obliteration of the arcuate artery by smooth muscle proliferation and mucoid change, with negative immunofluorescence studies. Blood film examination showed fragmented red blood cells. Interestingly, past medical history revealed an episode of measles-related immune thrombocytopenic purpura (ITP) at the age of 4 years. Despite treatment with plasma exchange, his renal failure progressed and he remained dialysis-dependent.
Comment
The only previous report of MMR-associated HUS was from France, describing an 18-month-old boy presenting with lower limb purpura and bloody diarrhoea 12 days after MMR vaccination [3]. On day 14, he developed acute renal failure, anaemia, and thrombocytopenia. Renal biopsy revealed thrombotic microangiopathy, with negative immune studies. Polymerase chain reaction (PCR) for Escherichia coli O157:H7 on blood and stool samples was negative.
The development of HUS following MMR vaccination in our patient does not prove causality. However, the fact that this patient had previously developed measles-related ITP suggests the patient had an underlying tendency to mount an abnormal reaction to the measles virus. On subsequent exposure to the measles component of the MMR vaccine, the patient again developed an abnormal reaction, manifesting clinically as HUS. HUS is also known to occur after other vaccinations. Filler et al. [4] reported a 10-year-old girl who developed diarrhoea-negative HUS after two vaccinations against early summer meningoencephalitis. This child had previously had HenochSchönlein purpura at the age of 6 years.
Renal disease has been reported following MMR vaccination. Ahuja and Wright in 1989 [5] reported the case of a young child who developed nephrotic syndrome 6 days after receiving the MMR vaccine.
Our case, together with the previously reported paediatric case of MMR-associated HUS, serves to flag up HUS as a potential complication of MMR vaccination, although does not confirm its underlying aetiology to be MMR vaccination. It also serves to remind physicians of the importance of taking a thorough infection and vaccination history. In this case, the complication of HUS could possibly have been avoided if the history of previous measles-associated ITP had been given sufficient attention. It is important, therefore, to be wary of unnecessary vaccination in immune patients, and in those with a tendency to develop infection- or vaccine-related autoimmune phenomena.
Notes
Email: yousuf.karim{at}gstt.sthames.nhs.uk
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