Measles-Associated Stridor

Measles is a highly contagious viral disease and a resurgent infection.1 Since the introduction of the measles vaccine in 1963, infection rates have declined to the extent that it had been considered nearly eradicated in America by 2000.2 However, outbreaks in undervaccinated or unvaccinated communities are on the rise globally, including in Europe and the United States, where the current outbreak is the largest in recent years.3 A concurrent major outbreak is being observed in Israel, particularly in the Jerusalem metropolitan area, with significant morbidity. Measles-associated stridor (MAS), which is indicative of upper airway obstruction, is a historically recognized but poorly characterized measles complication.4,5 This study evaluated the clinical characteristics of measles patients presenting with stridor including incidence, clinical presentation, admission rate, treatment, and outcome.A multicenter retrospective observational cohort study was conducted in 3 pediatric emergency departments (PEDs) from August 1 to October 31, 2025. Patients aged 0 to 17 years with polymerase chain reaction (PCR)-confirmed measles presenting with stridor were included. Disease severity was retrospectively assessed using the Westley Croup Score,6 a continuous measure of respiratory severity categorizing viral croup into mild (score 0–2), moderate (3–5), severe (6–11), and impending respiratory failure (12–17).Of the 317 PCR-confirmed measles cases, 39 patients (12%) had stridor as one of the presenting symptoms. Of these, 13 (33.3%) were female. Table 1 depicts demographic and clinical characteristics. The median age at presentation was 15 months (IQR 10–30.5), and 85% were unvaccinated. On presentation, 14 (35.9%) had a Westley score of 0 to 2, 15 (38.4%) had a score of 3 to 5, 9 (23%) had a score of 6 to 11, and 1 (2.5%) patient had a Westley score of 16. Thirty-five patients (89.7%) were hospitalized, and 7 (17.9%) were admitted to the pediatric intensive care unit (PICU). The main indications for admission included respiratory compromise in 30 (76.9%) patients and dehydration in 16 (41%). There were no deaths. The median length of stay in the hospital was 3 days (IQR 2–4).Other common presenting signs and symptoms included fever in 39 (100%) patients, a typical morbilliform rash in 37 (94.8%), signs of dehydration in 30 (76.9%), and cough in 23 (59%) patients. Respiratory support was administered to 27 (69.2%) patients, and high-flow nasal canula oxygen delivery was administered to 10 (25.6%). Four patients (10.2%) required more than 3 racemic epinephrine inhalations, and 3 (7.7%) patients required racemic epinephrine inhalations for more than 24 hours. Steroids were administered in the PED to 36 (92.3%) patients, whereas the other 3 (7.7%) received it prior to presentation to the PED. Antibiotics were administered to 27 (69.2%) patients. Vitamin A supplementation was administered to the 7 (17.9%) patients admitted to the PICU (Table 2).MAS is a significant complication of measles that affected 12% of the patients in this cohort. Severity was reflected in their clinical presentation and the higher general and PICU admissions rates when comparing with studies of common viral croup, which generally report mild symptoms, admission rate of 8.6%, and a PICU admission rate of 1% to 9%.7,8 MAS patients in this study had a total admission rate of 89.7% and 17.9% to the PICU. Although the median hospital length of stay for MAS is 3 days, the vast majority (82%) of patients admitted for typical viral croup have a length of stay of only 1 day.7Compared with previously described patients with croup, in which more than 90% of them had a Westley score of 0 to 3,9 in this MAS cohort, 43% had a Westley score of 4 or higher. The World Health Organization recommends vitamin A supplementation for all admitted children to reduce morbidity, including the risk of croup.10 In this cohort, vitamin A was administered only to patients admitted to the PICU, but earlier and broader use of vitamin A supplementation in children hospitalized with measles should be considered, including in settings not traditionally considered vitamin A deficient.11 This study had several limitations: Its retrospective and observational nature preclude ruling out viral or bacterial coinfection in some cases. The small sample size could have compromised the reliability of the analysis. Nevertheless, the findings reveal MAS to be a significant and common complication of measles in pediatric patients. Unlike other viral croup, the presentation is severe and the course is prolonged. In an era when measles outbreaks have become more common and widespread, clinicians should be familiarized with the specific characteristics of this disease.ChatGPT (OpenAI) was used solely to improve language and readability. All scientific content was reviewed and verified by the authors.