Download Ipsilateral Axillary Nerve Palsy and Corneal Ulceration complicating

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CENlllAL AFRICAN
JOURNAL OF MEDICINE
Several other complications have been reported
in other systems such as skin, mouth pharyx, middle
ear, brain and gastrointestinal tracts2.3.
Asindi et at' further elaborated on the lung complications of measles. Peripheral nerve involvement
which is common in other viral diseases has not been
previously reported in measles infection. The poor
immunological status of affected children seems to
worsen the complications of measlesS.6.
The axillary nerve (C5,6) accompanied by the
posterior circumflex humeral vessels escapes from
the axilla through a window medial to the surgical
neck of the humerus and the lower border of teres
mit;low. It gives off articular twigs to the shoulder
joint. and divides intoauterior and posterior branches;
the auterior braoch winds round the surgical neck
and both branches supply the deltoid and surrounding muscle.
Damage to the nerve produces little sensory disturbances but movements of the joint are greatly
impaired'.
CASE REPORT
Ipsilateral Axillary Nerve
Palsy and Corneal
Ulceration complicating
Severe Measles
A CASE REPORT
o ONUBA
SUMMARY
A three-year-old boy, who was previously healthy,
had a severe attack of measles which resulted in left
corneal ulceration with blindness and axillary nerve
palsy on the same side with subglenoid subluxation
of the humerus. The recovery of the function of the
nerve after one year of intensive physiotherapy was
negligible. This is an unusual complication of measle
as peripheral nerve involvement is rare.
INTRODUCTION
Measles is the most significant single cause of high
mortality and morbidity in young children in the
developing countries.
Ophathalamic complications such as conjunctivitis and blephritis are quite common and Sauter!
stated that measles may lead to loss of sight i.e. blindness.
All correspondence to:
OOnuba:
Department of Surgery
University ofCalabar Teaching Hospital
PMB 1278
Calabar
CASE REPORT
A E, a three-year-old healthy boy non-immunised
for measles but had triple vaccine in infancy suffered
a severe attack of measles which lasted one month.
During the prodromal period, the patient's mother
thought it was malaria and treated with self-medicated paracetamol and chloroquine, but medical help
was eventually sought three days later when the rash
appeared. There was no history of any antecedent
diarrhorea or colds.
By the end of the rust week, he had developed a
cough and bronchopneumonia The child was then
rushed to the University of Calabar Teaching Hospital Children Emergency Room.
The examining doctor discovered the beginning
of corneal ulceration and blephritis, intensive systemic antibiotics was started, as well as irrigation of
the eye with saline and local antibiotics.
Nutritional support was commenced and during
the third week the pneumonia subsided. At this time,
it was noticed the child could not lift his left arm
actively.
I
At the end of the fourth week, his clinical condition had improved. but gross wasting of the deltoid
was evident.
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CENTRALAFlUCAN
JOURNAL OF MFDIClNE
Vol 36, No. 1. JIDUUJ 1990.
Active elevation of the arm was only 45 degrees
and axillary nerve conduction was greatly reduced.
X-ray of the left shoulder showed a subglenoid
subluxation of the left humerus.
Despite a year of physiotherapy and nerve stimulation, active elevation remained less thal50percent
and thereafter the child was lost to follow up.
The corneal ulceration progressed to total blindness of the left eye.
normal but others leave pennanent disability such as
blindness, liver and brain damage and in our singular
case blindness and paralysis from peripheral nerve
palsy.
The expanded programme on the immunisation
(EPI) is the only hope for eradication of this deadly
disease in order to achieve the goal of health for all
by the year 2000 A.D.
DISCUSSION
1 Sauter11M, Xerophthalmia and measles in Kenya,
Croningen Drunker. Van Denderden. 1976
2 Effiong ,E. Immediate prognoiss of severe cases
of m~les admitted to University College Hospital, Ibadan.} Nat Med Assoc 1975; 455-460
3 Forbes C. Measles revisited., Medicine Digest.
1979; 5(3): 6-12.
4 Asindi A, Ani OAO, Pattern of measles in Calabar,Nig} Paed 1984; 11(4): 115-119.
5 Whittle HC, Cell-mediated immunity during natural measles infection.} ClinInvest 1978; 62: 678684.
6 Cho CT and Dudding BA, Paediatric infectious
disease 1st ed. Medical Examination Publishing
Co. Inc. New York. 1978.
7 Romanes GJ, Cunningham manual of practical
anatomy. Oxford University Press, Oxford. 1976;
8:45.
8 Morley DC, Martin WJ and Allen I, Measles
in West Africa. W Afr Med} 1967; 17: 24-31.
9 Hendrickse RG and Shennan PM, Morbidity and
mortality from measles in children seen at University College Hospital. Ibadan. Arch Fur Die
Gesamle Virusforshung. 1965; 16:27.
100sinusi K and Oyejide CO. Measles at the University College Hospital, Ibadan. An update. Nig
} Paed 1986;13: 53-57.
11 Coovadia HM, Alterations in immune responsivenessin acute measles and chronic post-measles
chest disease. Int Arch Allergy appl.Immunol
1978; 56: 14-23.
12 Hopkins GO, Ward AB and Garnett RAF, Lone
axillary nerve lesion due to closed non-dislocating injury of the shoulder . Injury 1985; 16(5):
305-306.
Severe measles (African measles), carries a high
mortality and morbidity and 10 per cent of hospitalisedcases die2.l·8.!1.10• The Nigerian Federal Ministry
of Health estimated in 1986 that in the absence of
immunisation, 36 million children will contract this
disease, with 108 000 deaths and 54 000 cases of
disabilities such as blindness, deafness undernutrition, chronic lung disease and liver disease.
Complications occur in the eyes such as blephritis, conjuctivitis, corneal ulceration, cataract and
blindness; in the brain encephalitis and convulsion;
skin rashes, desquamation and ulceration, anaemia,
intensinal parasitosis and lcwashi<>kor, cardiac failure23 nerve involvement has never ben reported.
In this repon corneal ulceration with blindness
and peripheral nerve involvement - axillary nerve
palsy with subglenoid subluxation of left humerus
were found. Peripheral nerve lesions are more commonly associated with other viral diseases like poliomyelitis. Several workers5.6·11 have confirmed immunodepression with malnutrition as the cause of
the various complications.
As there was no previous viral illness, injury or
birth trauma in this patient, measles was probably
responsible for the palsy. The absence of recovery of
the nerve after one year means that it was either a root
lesion (C5,6) or lesion proximal to teres minor.
Traumatic damage to the nerve distal to teres
minor usually recovers well 12• Treaunent requires
hospitalisation and intensive supportive nutrition
and antibiotics. Some of the complications such as
skin, cardiac and anaemia improve and return to
REFERENCES
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