Clinical Zoom meeting snippets - February 2025

Issue 60 of Paediatric Vaccines Research Review included comment on a recently published article in J Child Neurology on pediatric subacute sclerosing panencephalitis complicating measles and the future of measles vaccination.

• SSPE is a rare but invariably fatal complication of measles that can develop years after infection, particularly affecting those infected before age two. The latency period between acute measles and first symptoms of SSPE is usually 4 to 10 years but ranges from 1 month to 27 years. Characterised by progressive neurological decline, SSPE leads to death usually within 1–3 years of onset. 

• Measles vaccination has drastically reduced SSPE cases, highlighting the importance of maintaining high immunisation coverage. SSPE, while rare, still remains a devastating potential outcome of measles, reminding us that vaccination extends beyond immediate benefits. 

• The commentator notes we rarely discuss SSPE – perhaps due to its low incidence – but as a life-altering complication it’s crucial to acknowledge and address its risks. A study from Germany published in 2013 found that children under 5 years of age when they contracted measles had a 1 in 1700–3300 risk of SSPE noting this risk is in the same order of magnitude as the risk of a fatal acute measles infection. A study from Georgia published in 2020 found a similar incidence (crude incidence as high as 1:158 – 1:1580 (depending on estimates of measles reporting) for onset of measles at <1 year of age.  These figures are somewhat different to the 1:100,000 incidence quoted in current ImAC measles resources.  

• Should we then bring this into our public health conversations as a stark reminder of measles’ broader dangers? Doing so could strengthen advocacy for vaccination, especially for early childhood immunisation in vulnerable populations.

• I have recently reviewed a complaint relating to failure to inform a patient of their progressive lymphocytosis over several years. On transferring to a new practice, they were diagnosed with CLL and informed of the preceding abnormal results.  Blood counts had been done occasionally over several years by the previous GP for symptoms unrelated to CLL but in addition to failing to inform the patient (who was well) of the abnormality, there was no structured monitoring in place.   

• Health Pathways notes that transient increases in the lymphocyte count (lymphocytosis) are usually due to acute infections, such as Epstein-Barr virus infection and viral hepatitis, cytomegalovirus infection, HIV/AIDS. Less commonly, increased lymphocytes may be the result of pertussis and toxoplasmosis, or tuberculosis and brucellosis. The lymphocyte count may also be elevated in smoking, post-splenectomy, acute stress response, trauma and autoimmune thyroiditis. 

• Look for associated anaemia, neutropenia, or thrombocytopenia. Assess for any clinical signs of infection or inflammation including lymphadenopathy and hepatosplenomegaly which may represent a lymphoproliferative disorder. 

• If there is persistent lymphocytosis, consider:
  • autoimmune conditions, e.g. rheumatoid arthritis.
  • post-splenectomy.
  • monoclonal B-cell lymphocytosis, a clonal lymphocytosis similar to chronic lymphocytic leukaemia (CLL), but with clonal lymphocytes less than 5 x 10⁹/L and without other features of CLL.
  • B-cell chronic lymphocytic leukaemia (B-CLL). 

• Request a haematology assessment or seek haematology advice if lymphocytosis with:
  • anaemia, neutropenia, or thrombocytopenia.
  • lymphadenopathy or hepatosplenomegaly.
  • rapidly rising lymphocyte count or blast cells present. 

• If the patient is well or has mild symptoms with lymphocyte counts 7 x 10⁹/L or less, recheck white blood cell count in 2 to 3 months. Reactive lymphocytosis generally resolves within 2 months. A stable increased lymphocyte count in an otherwise well person is unlikely to require treatment. 

• If persistent lymphocytosis is greater than 7 x 10⁹/L, consider a lymphoproliferative disorder (most commonly B-CLL) and if the immunophenotyping confirms a clonal population, follow the B-cell Chronic Lymphocytic Leukaemia (B-CLL) Pathway which advises when to seek haematology advice if clinically appropriate and gives specific monitoring advice.

• From mid-December 2024, medical practitioners and nurse practitioners have been required to send a Preliminary Notice of Death (PNOD) to Births, Deaths and Marriages (BDM) within 3 days of completing a Medical Certificate of Cause of Death (MCCD). 

• For those completing the MCCD online in Death Documents, the notice is sent automatically when the certificate is submitted. Practitioners not currently registered to use Death Documents to complete a MCCD are encouraged to do so. 

• If a practitioner is not using Death Documents they need to complete a new PNOD form and email it to BDM. The PNOD contains a subset of the information contained on the MCCD and will be able to be completed on screen and emailed to BDM as an attachment. A digital signature can be accepted. Further information is available on Te Whatu Ora's website.

• Under normal circumstances, there is a requirement under Regulation 7 of the Cremation Regulations 1973 for the practitioner completing a cremation certificate to view the body of the deceased after death. Exemption from this requirement under specific circumstances has been in force since 2020 and was recently extended to 31 December 2025. The exemption applies only in the following circumstances: 
  • the death occurs in rest homes, residential care facilities, and other long-term in-patient facilities; and
  • the death is not unexpected; and
  • where the medical history and current conditions of the deceased are known by a medical or nurse practitioner. 

• This exemption does not apply to deaths in public hospitals, hospices, private homes, or other settings and where a medical practitioner does not know the medical history of the individual. Certifying practitioners are still required to view the body of a person who dies outside of a residential care facility in order to issue a cremation certificate. 

• Under this authorisation a medical referee must receive advice from a trusted source (usually a manager or registered nurse at the residential facility) who has a reasonable level of assurance of the cause of death to verify the identity of the deceased and that the deceased died of natural causes. 

• Under the exemption the Form B cremation certificate should be completed by a certifying practitioner who previously attended the deceased before death (by personal attendance or via video-link) and should state that “the deceased was not examined after death as per the Minister's residential care facility exemption”. A practitioner who did not attend the deceased before death must still examine the body after death in order to issue a medical certificate of cause of death.  It is still important to determine whether the deceased has a pacemaker or biomechanical aid and to complete the appropriate certification in this regard.  Further information is available on Te Whatu Ora's website. 

• A reminder in the December 2024 Prescriber Update that acyclovir and valaciclovir can accumulate in patients with renal impairment. Therefore, a dose adjustment is needed in these patients to reduce the risk of risk of neurotoxicity.  NZ Formulary gives specific dosing instructions for various creatinine clearance (CC)measurements eg using valaciclovir for herpes zoster, CC 30–50 mL/minute, 1 g every 12 hours, CC 10–30 mL/minute, 1 g every 24 hours, CC less than 10 mL/minute, 500 mg every 24 hours.   Advice is to monitor patients with renal impairment closely for signs of neurotoxicity, which may include confusion, agitation, hallucinations or seizures. 
• The January 2025 NZF update includes new cautions added to the prescribing information for medroxyprogesterone acetate (MPA - Provera, Depo Provera): history of meningioma; increased risk of meningioma with prolonged use of injection or high oral doses (100 mg or more), discontinue if meningioma is diagnosed.  A recent French study showed no excess risk of intracranial meningioma for progesterone, dydrogesterone, or levonorgestrel intrauterine systems.  The meningioma warning has been in place for cyproterone acetate (CPA) for a number of years (see 2020 Prescriber Update) mainly in doses 25mg or higher and with extended use, with current meningioma or history of meningioma being a contraindication to use.  CPA may be used for androgen blockade in transgender therapy as well as in women for severe signs of androgenisation. The cited study found odds ratio of 5.55 for MPA and 19.21 for CPA for development of meningioma.  However, the background annual incidence of meningioma is low (9.7/100,000 in the US) although 2-3 times more common in females than males.  
• A recent Goodfellow Unit GEM notes serological testing for herpes simplex virus (HSV) is not recommended in most cases of genital herpes due to its accuracy and clinical utility limitations. Serology detects past exposure to HSV but cannot confirm active infections or distinguish between genital and facial infections. HSV IgG antibodies may take weeks to months to develop, leading to false negatives in early infection, and even seropositive individuals may revert to seronegative status. Genital herpes screening is not recommended and is likely more harmful than helpful.  Viral swab PCR testing from active lesions is the gold standard in NZ for accurate diagnosis. The New Zealand Herpes Guidelines advise that HSV-1 and HSV-2 serology is not recommended except in rare, specific situations (e.g., an asymptomatic pregnant partner of a newly diagnosed person); discuss these with a sexual health specialist. See the national guidelines for management of genital herpes for more information. 

• A validated rapid (3-4 minutes) screening test for cognitive impairment is the Mini-Cog. Follow-up abnormal testing with a suitable multi-domain test. 
• For patients with limited English, the Rowland Universal Dementia Assessment Scale (RUDAS) is specifically designed for use in culturally/linguistically diverse population and is validated when administered in English with a medical interpreter. The link includes specific instructions on how to administer the test with an interpreter. 
• A combined brief (4 minute) patient screening and informant interview (if indicated by patient screening – takes 2 minutes) is the GPCOG test.  Printable versions of the test in various languages and an online version are available on the GPCOG website together with a training video. 
• Melanoma counselling - The Melanoma New Zealand Counselling Service supports anyone affected by melanoma, including individuals, families, whānau and carers facing the challenges of a new diagnosis, ongoing treatments, or post treatment. Free, and online or by phone, our counselling service offers you an opportunity to safely explore your thoughts and emotions with a professional counsellor, in complete confidence.  Up to four x 50 minute counselling sessions are available on self-referral or referral via a health professional.  The Melanoma NZ website also contains a wealth of resources for patients around all aspects of melanoma prevention, diagnosis and treatment. 
• The December issue of NZ Doctor includes an article on the Post-Covid Syndrome symptom map which can be downloaded as a PDF from the Manatu Hauora Long Covid rehabilitation website along with guidelines and other clinical resources for managing the condition.  The article notes the map can be sent to the patient to complete in advance of their appointment, ensuring 15-minute appointment times are optimised. In addition, it can reduce patient fatigue, ensuring the patient does not expend precious energy retelling their story, by providing a representation of their situation which can be easily shared with other clinicians involved in their care.  From a GP’s perspective, the PCSM gets straight to the heart of the issue, highlighting attention to multisystem involvement and capturing both symptom severity and functional disability. The PCSM saves time by ruling out red flags or, conversely, highlighting the need for further investigations, thereby directing immediate care or onward referral. For complex patients who present with a multitude of symptoms without any discernible pattern, it provides a useful starting point from which to move forward.