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rubella (German measles, 3rd disease)

Etiology: 1) rubella virus 2) transmission a) probably via respiratory droplets b) patients are most contagious when rash is erupting c) viral shedding occurs from 10 days prior to & 15 days after eruption of rash Epidemiology: - progress on elimination of measles & rubella 2000-2011 [4] Clinical manifestations: 1) postnatal infection a) incubation period is 15-21 days b) prodromal symptoms may precede rash by 1-5 days c) lymphadenopathy - begins 1-5 days prior to the rash - suboccipital, postauricular & general - may be the only sign of infection d) rash appears at the same time as the low-grade fever - appears 1st on the face, then progresses down the body - maculopapular rash, discrete often pinpoint lesions occasionally coalescing on the trunk - duration of rash 3-5 days - occasional desquamation during convalescence e) petechial lesions on soft palate f) mild conjunctivitis g) fever - low-grade or absent - resolves by 1st day of rash 2) congenital infection a) manifestations are most severe the earlier in pregnancy the illness occurs b) fetal demise c) premature delivery d) congenital anomalies - nerve deafness (80-90%) - growth retardation (50-85%) - congenital cataracts (35%) [6] (image) - retinopathy (35%) [6] (image) - patent ductus arteriosus (30%) - pulmonary artery &/or valvular stenosis (30%) - atrial septal defect - mental retardation (10-20%) - meningoencephalitis (10-20%) - behavioral disorders (10-20%) - hepatosplenomegaly (10-20%) - bone lesions (10-20%) - thrombocytopenic purpura (5-10%) Laboratory: 1) generally not useful in diagnosing acute disease 2) rubella virus antigen in tissue/body fluid - specimen from nose, throat, urine or other body fluid for diagnosis of congenital infection 3) rubella virus serology: a) confounded by false positives b) presence in infant suggests congenital infection 4) rubella virus RNA - rubella virus E1 gene 5) see ARUP consult [3] Differential diagnosis: 1) enteroviral infection a) shorter incubation period (3-7 days) b) more common in younger children c) frequently with higher fever d) seasonal, more common in summer & fall 2) measles 3) scarlet fever 4) infectious mononucleosis 5) toxoplasmosis 6) roseola 7) erythema infectiosum 8) drug reactions Complications: (rare) 1) arthritis & arthralgia more common in adult women 2) thrombocytopenia 3) leukopenia 4) encephalitis (very rare) Management: 1) symptomatic treatment for postnatal infection 2) pharmacologic agents a) acetaminophen for fever b) aspirin for arthralgia 3) prophylaxis: a) MMR vaccine b) immune globulin for susceptible pregnant women with < 20 gestation within 72 hours of exposure (controversial) 4) isolation from susceptible individuals until 7 days after the rash 5) complete Confidential Morbidity Report; rubella is a reportable disease

Related

measles, mumps & rubella combined vaccine (MMR) rubella virus

General

viral infection childhood exanthem (numbered diseases)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 868-69
  2. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1039
  3. ARUP Consult: Rubella Virus The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/rubella-virus
  4. Papania MJ et al Elimination of Endemic Measles, Rubella, and Congenital Rubella Syndrome From the Western Hemisphere. The US Experience. JAMA Pediatr. Published online December 05, 2013. PMID: 24311021 http://archpedi.jamanetwork.com/article.aspx?articleid=1787786 - Grabowsky M The Beginning of the End of Measles and Rubella. JAMA Pediatr. Published online December 05, 2013 PMID: 24310954 http://archpedi.jamanetwork.com/article.aspx?articleid=1787785 - Centers for Disease Control and Prevention Rubella and Congenital Rubella Syndrome Control and Elimination - Global Progress, 2000=2012. MMWR. Weekly. December 6, 2013 / 62(48);983-986 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6248a3.htm
  5. Pan American Health Organization (PAHO) & World Health Organization (WHO) April 29, 2015 Americas region is declared the world's first to eliminate rubella. http://www.paho.org/hq/index.php?option=com_content&view=article&id=10798%3Aamericas-free-of-rubella&catid=740%3Anews-press-releases&Itemid=1926&lang=en
  6. Matalia J, Shirke S Congenital Rubella N Engl J Med 2016; 375:1468 October 13, 2016 PMID: 27732820