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First report of measles with natalizumab: case report A 35-year-old woman developed measles after receiving measles-mumps-and-rubella virus vaccine and following treatment with natalizumab for relapsing-remitting multiple sclerosis (RRMS) [route and dosage not stated]. The woman, who had RRMS, had been receiving natalizumab injections for 3 years. For practical reason, she wanted to switch to oral medication. Therefore, she was referred to a vaacination clinic to update her vaccine prior to switching her treatment to fingolimod (treatment with established immunosuppressive properties). Due to the lack of immunity to measles, she received measles-mumps-and-rubella virus vaccine. She was also immunised with influenza virus vaccine, hepatitis-A vaccine, diphtheriavaccine, tetanus-vaccine, pertussis-vaccine and pneumococcal-13-valent-CRM197 vaccine conjugate [pneumococcal 13-valent vaccine]. Seven days after the vaccination, she started experiencing fatigue and diffuse muscle pain. On day 9 after the vaccination, she developed fever, and two days later, she developed sore throat and an erythematous maculopapular rash, which spread from trunk and face to her extremities. She had no infectious exposure or travel history. On day 6 of the symptoms, she consulted a general medicine at an outpatient clinic. Physical examination revealed an erythematous maculopapular rash, slightly inflamed tonsils and submandibular and posterior right cervical lymph nodes. Blood tests revealed normal white blood cell count and slightly elevated C-reactive protein. A rapid throat test for streptococcus was positive. Hence, differential diagnoses included vaccineassociated measles or acute streptococcal pharyngitis with scarlet fever. The woman was treated with amoxicillin for six days. Two days after the initiation of antibiotics, her fever broke with improvement in all her symptoms. Eight days after the initiation of antibiotics, she sought medical attention in the vaccination clinic. During this, she was asymptomatic, and physical examination was unremarkable, except her fading rash with no desquamation. Real time-PCR for measles was performed, which was positive with 1100 copies/mL. Tests for other common respiratory viruses were negative. Due to small quantity of RNA, typisation of measles starin was not possible. The time line of the vaccination and onset of her symptoms corresponded typically vaccine-associated measles. Miauton A, et al. Vaccine-associated measles in a patient treated with natalizumab: a case report. BMC Infectious Diseases 20: 753, No. 1, 2020. Available from: URL: http:// 803515876 doi.org/10.1186/s12879-020-05475-9

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Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of measles associated with natalizumab. The WHO ADR database contained one report of measles associated with natalizumab.

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Reactions 21 Nov 2020 No. 1831