Journal of Medical Virology 83:2004–2007 (2011)

Case Report

Simultaneous Infection of Measles andVaricella-Zoster Virus in a Child in India

Dipankar Biswas,* Kaushal Yadav, Biswajyoti Borkakoty, and Jagadish Mahanta

Regional Medical Research Centre, NE Region (Indian Council of Medical Research), Dibrugarh, Assam, India

Simultaneous occurrence of measles and chick-enpox in a single individual is a rare eventdespite the fact that each of these infectionsalone is very common. The clinical presentationand molecular characterization of a dual infec-tion caused by measles and Varicella-Zostervirus (VZV) in a 3-year female child is reportedfor the first time from India. The child pre-sented with high fever, cough, cervical lymph-adenopathy, and maculopapular rash followedby vesicular skin rash. The child was not immu-nized against measles and chickenpox. Theviral nucleic acids extracted from the clinicalspecimen were subjected to PCR-Sequencingfor confirmation of a dual infection withmeasles and VZV. The PCR and sequenceanalysis from the throat swab samples con-firmed the coinfection of wild-type measles(genotype D4) and Varicella-Zoster virus (PstIþ

BglIþ). The measles virus RNA and VZV DNAcould be detected successfully from a singlespecimen of a throat swab. The case recovereduneventfully. Dual infection with measles andVZV does occur but may be underreported inthe literature. J. Med. Virol. 83:2004–2007,2011. � 2011 Wiley-Liss, Inc.

KEY WORDS: measles; Varicella-Zoster virus;VZV; genotype; India

INTRODUCTION

Measles is a highly contagious disease caused bymeasles virus, an enveloped virus with a single-stranded, negative sense RNA genome which is amember of the genus morbillivirus within the familyParamyxoviridae. Measles virus causes a diseasecharacterized by high fever, cough, coryza, conjuncti-vitis, and appearance of a maculopapular rash[Griffin, 2001]. The global mortality attributed tomeasles was estimated to be 197,000 deaths in 2007[CDC, 2008]. Another common childhood disease,chickenpox caused by Varicella-Zoster virus which is

a member of the human herpes virus family, is also ahighly contagious. It is characterized by disseminatedvesicular skin rash with fever [Whitley, 1995].Although a live attenuated vaccine has been availablesince 1974 [Takahashi et al., 1974], chicken poxremains a major childhood infection. Though bothinfections are ubiquitous in developing countries, dualinfection with both viruses simultaneously is veryrare. A case of simultaneous infection with measlesand Varicella-Zoster virus in an urban slum locality ofAssam, northeast India is presented here.

CASE REPORT

During a measles outbreak investigation (May,2009) in an urban slum area of the Dibrugarh districtof Assam, a 3-year-old female child presented withclinical features of fever (1018F), cough, coryza, con-junctival congestion, cervical lymphadenopathy, andboth maculopapular (characteristic of measles) andvesicular skin rash (characteristic of chickenpox)(Fig. 1). The child was not immunized against measlesand chicken pox. The child was irritable and hadgeneralized weakness with poor nutritional status.The parents refused a blood sample from the childdue to religious beliefs; however, they consented to athroat swab. The throat swab specimen collected inviral transport media containing balanced salt solu-tion and antibiotics were transported to laboratory forvirological investigations. A prior written informedconsent was obtained from the parents of the childand the study was approved by the Institutionalethical committee of the Regional Medical ResearchCentre, Dibrugarh.

*Correspondence to: Dipankar Biswas, Regional MedicalResearch Centre, NE Region (Indian Council of MedicalResearch), P.O. Box 105, Dibrugarh 786001, Assam, India.E-mail: biswas_dip@yahoo.com

Accepted 18 July 2011

DOI 10.1002/jmv.22206Published online in Wiley Online Library(wileyonlinelibrary.com).

� 2011 WILEY-LISS, INC.

VIROLOGICAL INVESTIGATIONS

Viral RNA of measles virus was extracted from thethroat swab using the QIAamp viral RNA kit of Qia-gen (Hilden, Germany) and viral DNA for VZV wasextracted by the standard Phenol-Chloroform method[Sambrook and Russell, 2001]. Viral RNA was sub-jected to one step RT-PCR using one step RT-PCR kit(Qiagen) with the measles nucleoprotein gene(N gene) primers MV60 (50-GCTATGCCATGGGAGTAGGAGTGG-30) and MV63 (50-GGCCTCTCGCACC-TAGTCAG-30) in a thermal cycler (MyCycler; BioRad,Hercules, CA) using previously described protocol[Cheng et al., 2007]. The PCR product was purifiedusing High pure PCR product purification kit (Roche,Mannheim, Germany) and subjected to dideoxy cyclesequencing in both directions (3130 genetic analyzer,Applied Biosystems, Hitachi, Japan) using the aboveprimers. The sequences were edited with a Bioedit

software v 7.09 [Hall, 1999] and a partial N gene se-quence was used for construction of phylogenetic treeusing WHO standard reference strains of measlesvirus [WHO, 2007]. In case of VZV DNA, PCR amplifi-cation was done for two well-known markers, PstI atposition 69360 in ORF 38 and BglI at position 95241in ORF 54 of VZV genome using primers and methodsas described by LaRussa et al. [1992]. The purifiedPCR products were sequenced directly in both thedirections and the sequences were submitted to theNCBI-GenBank.

The sequence analysis done on the 580 bp of thePCR amplified product for the measles virus N gene(Fig. 2) confirmed that the child was infected withmeasles virus of genotype D4 (GenBank AccessionNo.HM626276) (Fig. 3). The sequence analysis(GenBank accession no. HM641899, HM754613) doneon the 220 bp (Fig. 4) and the 350 bp (Fig. 5) DNAfragments using primers targeting VZV genome

Fig. 1. The case of a dual infection with measles and Varicella-Zoster virus showing both maculopap-ular and vesicular skin rash.

Coinfection of Measles and Varicella-Zoster Virus 2005

J. Med. Virol. DOI 10.1002/jmv

revealed the presence of PstI and BglI restriction siteat ORF 38 and ORF 54, respectively.

DISCUSSION

The confirmation of a concurrent infection by mea-sles and Varicella-Zoster virus from a single specimenof throat swab was based on PCR and subsequent nu-cleotide sequencing. The patient was found to beinfected with measles virus D4 which is a wild-typestrain distributed widely and associated with multipleoutbreaks in the Indian sub-continent, East andSouth Africa and was also reported during a largeoutbreak in the Quebec Province, Canada in 1989[Riddell et al., 2005]. While the VZV strain isolatedfrom the child revealed the presence of VZV wild typestrain (PstIþ BglIþ). The ‘‘PstIþ BglIþ’’ is a commongenotype among Indian VZV strains [Kaushik et al.,2008]. The child had early clinical features character-istics of measles which was followed 4 days later by avesicular skin rash typical of chicken pox. Artensteinand Weinstein [1963] estimated that about 15 cases ofsimultaneous infection with measles and VZV mayhave occurred in the state of Massachusetts in 1961.It has been noted on occasion that chickenpox andmeasles might occur together or one may precede the

Fig. 2. Gel photograph showing 580 bp amplicon of measles virusN-gene.

Fig. 3. Dendrogram showing measles virus D4 genotype (MVs/Dibrugarh.Ind/20.09/6) in the reported case. Multiple alignmentswere performed using WHO measles reference sequences and a fewsequences from India using CLUSTAL W in MEGA v4.01. Phyloge-netic tree was constructed by Neighborhood joining method usingkimura 2 parameter in MEGA software. Bootstrapping was done for1,000 replicates.

Fig. 4. Gel photograph showing 220 bp amplicon of VZV gene 38.

2006 Biswas et al.

J. Med. Virol. DOI 10.1002/jmv

other by a few days [Artenstein and Weinstein, 1963].On the other hand, Merigan et al. [1968] noted theoccurrence of both infections within a few weeks inseven of 18 children who were admitted to a youthguidance centre. Knight et al. [1964] reported a casewith the onset of measles one week following chicken-pox. The most remarkable observation in the presentcase of dual infection was the appearance of apparent-ly a clear zone of normal skin around the chicken poxlesions that might be due to viral interference. It wasalso observed that there was scanty distribution of ve-sicular lesion typical of chicken pox. Further, as seenfrom the uneventful recovery of the child, prior infec-tion with measles seems to have diminished the skinlesions specific for chickenpox rather than exacerbat-ing them. A similar phenomenon of viral interferencewas also observed by Merigan et al. [1968] and Knightet al. [1964] during concurrent Varicella and measlesinfection. During the last four decades there seems tobe no reported case of dual infection in the literature,and this is probably the first reported case of dual in-fection with measles and Varicella-Zoster virus inIndia. However, both infections are still very common

during childhood particularly in developing countriesand dual infection with measles and chickenpox virus-es may be underreported. In most parts of suburbanand rural India, medical consultations for measlesand chickenpox are sought rarely after and the casesare mostly managed at home due to religious beliefs.It is also possible that dual infection may result indiminished virulence and complications which also ac-count for the under recognition of such cases of dualinfection.

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Fig. 5. Gel Photograph showing 350 bp amplicon of VZV gene 54.

Coinfection of Measles and Varicella-Zoster Virus 2007

J. Med. Virol. DOI 10.1002/jmv