Manzotti, Francesca

Menozzi, Chiara

Orsoni, Jelka G

Porta, Maria R

English

PubMed

Francesca Manzotti

Chiara Menozzi

Maria R Porta

Jelka G Orsoni

Springer - Publisher Connector

LETTER TO THE EDITOR Open Access
Partial third nerve palsy after Measles Mumps
Rubella vaccination
Francesca Manzotti*, Chiara Menozzi, Maria R Porta, Jelka G Orsoni
Abstract
Background: Measles Mumps Rubella (MMR) vaccination is known to cause some serious adverse events, such as
fever, rash, gland inflammation and neurologic disorders. These include third and sixth cranial nerve palsies.
Results: The case reported describes a partial recurrent oculomotor palsy associated with systemic symptoms
following MMR vaccination in a healthy young child. The oculomotor palsy did not recover completely during the
follow-up.
Conclusions: Most of the times, measles, mumps and rubella cause mild illness and discomfort; but can also have
serious or fatal sequelae. MMR vaccination has been proved to be safe and to reduce significantly the number of
reported infections due to these viruses. However, significant adverse events can occur and paediatricians and
public health operators should be aware of this aspect.
Partial third nerve palsy after Measles Mumps
Rubella vaccination
Sir,
Measles Mumps Rubella (MMR) vaccination is known
to cause some serious adverse events. These can include
fever, rash, gland inflammation and neurologic disorders
like epilepsy, encephalitis, aseptic meningitis and autistic
disorders [1,2].
The case reported below describes a partial recurrent
oculomotor palsy following MMR vaccination in a
healthy young child.
Case Report
A 20-month-old Italian boy received a MMR (MMR
VAX PRO®) vaccine dose according to the normal vacci-
nation schedule. Twenty days later he presented fever
and cutaneous rash, which resolved spontaneously in one
day, and left eye (LE) eso-hypotropia, which also lasted
24-48 hrs until complete self-recovery. This episode
recurred 20 days later: the ophthalmological examination
showed a deficit of elevation in adduction of the LE and
was diagnosed as “acquired palsy of the inferior oblique
muscle” [Fig. 1]. The remaining neurologic examination
was normal. EEG, brain MRI with and without
gadolinium, blood count, blood chemistry were normal.
Serum titres against main viral agents (Citomegalovirus,
Epstein-Barr, Herpes Simplex, Varicella Zoster, Papova-
virus B19, Influenza, Parainfluenza, Respiratory Syncytial)
were negative, except for a positive IgG titre for Rubella
virus. A week later the symptoms partially disappeared
without any treatment. The following scheduled neurolo-
gical controls continued to be normal, while the orthoptic
examination showed persisting, but inconstant, weakening
of LE inferior oblique muscle function. At the last con-
trol, when the child was 5 years old, visual acuity and
stereopsis tests were normal, but a mild deficit of the
inferior oblique muscle function persisted, with ortho-
phoria in primary position.
Discussion
MMR viruses are neurotropic. Therefore, although the
vaccine is obtained by live attenuated viruses, vaccina-
tion may produce neurological disorders. Only a few
cases of benign, recurrent cranial nerve palsies, second-
ary to immunization, have been described. Patients with
complete palsy of the third [3] or sixth [4-7] cranial
nerve have been reported. In our case, the oculomotor
nerve palsy is incomplete i.e. only the inferior oblique
muscle is involved in one eye. The previously reported
cases resolved spontaneously and completely within
several months. In our case, however, a mild deficit of
* Correspondence: francesca_manzotti@virgilio.it
Department of Cervico-Facial Sciences, Institute of Ophthalmology,
University of Parma, Parma, Italy
Manzotti et al. Italian Journal of Pediatrics 2010, 36:59
http://www.ijponline.net/content/36/1/59 ITALIAN JOURNAL 
OF PEDIATRICS
© 2010 Manzotti et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
the muscle has persisted several years following vaccina-
tion and may be considered permanent.
In conclusion, public confidence in immunization
must be maintained because safety and efficacy of MMR
vaccination is clearly demonstrated; however potential
adverse events must be strictly and carefully monitored.
Received: 27 July 2010 Accepted: 10 September 2010
Published: 10 September 2010
References
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2. Mäkelä A, Nuorti PN, Peltola H: Neurologic disorders after Measles-
Mumps-Rubella vaccination. Pediatrics 2002, 110:957-963.
3. Chan CC, Sogg RL, Steinman L: Isolated oculomotor palsy after Measles
immunization. Am J Ophthalmol 1980, 12:119-128.
4. Werner DB, Savino PJ, Schatz NJ: Benign recurrent sixth nerve palsies in
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doi:10.1186/1824-7288-36-59
Cite this article as: Manzotti et al.: Partial third nerve palsy after Measles
Mumps Rubella vaccination. Italian Journal of Pediatrics 2010 36:59.
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Figure 1 Deficit of elevation in adduction of the LE.
Manzotti et al. Italian Journal of Pediatrics 2010, 36:59
http://www.ijponline.net/content/36/1/59
Page 2 of 2


Partial third nerve palsy after Measles Mumps Rubella vaccination

Benign recurrent abducens (sixth) nerve palsy.

Isolated oculomotor palsy after Measles immunization.

KL: Measles, Mumps, Rubella Vaccine (Priorix; GSKMMR): a review of its use in the prevention of Measles, Mumps and Rubella. Drugs

Neurologic disorders after MeaslesMumps-Rubella vaccination. Pediatrics

NJ: Benign recurrent sixth nerve palsies in childhood secondary to immunisation or viral illness. Arch Ophthalmol

Recurrent isolated sixth nerve palsy after consecutive annual influenza vaccinations in a child.

Recurrent sixth nerve palsy following Measles Mumps Rubella vaccination. Eye

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2944153

Partial third nerve palsy after Measles Mumps Rubella vaccination

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