Rubella (German Measles)

Sabah Mohsin Al-Maamuri MD

FICPS
characteristic. This often precedes the rash or may
occur without rash. The rash consists of
Essentials of diagnosis & typical features erythematous discrete maculopapules beginning on
 History of rubella vaccination usually absent. the face. A “slapped-cheek” appearance or pruritus
 Prodromal nonspecific respiratory symptoms may occur. Scarlatiniform or morbilliform rash
and adenopathy (postauricular and variants may occur. The rash spreads quickly to the
occipital). trunk and extremities after it fades from the face; it
 Maculopapular rash beginning on face, is gone by the fourth day. Enanthem is usually
rapidly spreading to the entire body, and absent.
disappearing by fourth day. 2. Congenital infection—More than 80% of women
 Few systemic symptoms. infected in the first 4 months of gestation are
 Congenital Infection. delivered of affected infants; congenital disease
 Retarded growth, development. occurs in less than 5% of women infected later in
 Cataracts, retinopathy. pregnancy. Later infections can result in isolated
 Purpuric “blueberry muffin” rash at birth, defects, such as deafness. The main manifestations
jaundice, thrombocytopenia. are as follows:
 Deafness.
 Congenital heart defect. a. Growth retardation. Between 50% and 85% of
infants are small at birth and remain so.
b. Cardiac anomalies. Pulmonary artery stenosis,
General Considerations patent ductus arteriosus, ventricular septal defect.
If it were not teratogenic, rubella would be of little c. Ocular anomalies. Cataracts, microphthalmia,
clinical importance. Clinical diagnosis is difficult in glaucoma, retinitis.
some cases because of its variable expression. In
one study, over 80% of infections were subclinical. d. Deafness.
Because of inadequate vaccination, outbreaks now e. Cerebral disorders. Chronic encephalitis.
occur in adolescents or adults. Rubella is
transmitted by aerosolized respiratory secretions. f. Hematologic disorders. Thrombocytopenia,
Patients are infectious 5 days before until 5 days dermal nests of extramedullary hematopoiesis or
after the rash. purpura (“blueberry muffin” rash), lymphopenia.

Congenital rubella, in infants both of unimmunized g. Others. Hepatitis, osteomyelitis, immune

women and of women who have apparently been disorders, malabsorption, diabetes.
reinfected in pregnancy, is now rare.
B. Laboratory findings:
Clinical Findings:
Leukopenia is common, and platelet counts may be
The incubation period is 14–21 days. The
low. Congenital infection is associated with low
nondistinctive signs may make exposure history
platelet counts, abnormal liver function tests,
unreliable. A history of immunization makes rubella
hemolytic anemia, pleocytosis, and very high rubella
unlikely but still possible. Congenital rubella usually
IgM antibody titers. Total serum IgM is elevated,
follows maternal infection in the first trimester.
and IgA and IgG levels may be depressed.
A. Symptoms and signs: C. Imaging:
1. Infection in children—Young children may only
have rash. Older patients often have a nonspecific Pneumonitis and bone metaphysial longitudinal
prodrome of low-grade fever, ocular pain, sore lucencies may be present in x-rays of children with
throat, and myalgia. Postauricular and suboccipital congenital infection.
adenopathy (sometimes generalized) is
Diagnosis & Differential Diagnosis:
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Virus may be isolated from throat or urine from 1 with a low mortality rate. A syndrome resembling
week before to 2 weeks after onset of rash. Children subacute sclerosing panencephalitis has also been
with congenital infection are infectious for months. described in congenital rubella.
The virus laboratory must be notified that rubella is
C. Rubella in pregnancy:
suspected. Serologic diagnosis is best made by
demonstrating a fourfold rise in antibody titer Infection in the mother is self-limited and not severe.
between specimens drawn 1–2 weeks apart. The
first should be drawn promptly, because titers Prevention:
increase rapidly after onset of rash. Both specimens
Rubella is one of the infections that potentially could
must be tested simultaneously by a single
be eradicated. Standard prenatal care should
laboratory. Specific IgM antibody can be measured
include rubella antibody testing. Seropositive
by immunoassay. Because the decision to terminate
mothers are at no risk; seronegative mothers are
a pregnancy is usually based on serologic results,
vaccinated after delivery.
testing must be done carefully.
A pregnant woman possibly exposed to rubella
Rubella may resemble infections due to enterovirus,
should be tested immediately; if seropositive, she is
adenovirus, measles, EBV, roseola, parvovirus,
immune and need not worry. If she is seronegative,
Toxoplasma gondii, and Mycoplasma. Drug
a second specimen should be drawn in 4 weeks,
reactions may also mimic rubella. Because public
and both specimens should be tested
health implications are great, sporadic suspected
simultaneously. Seroconversion in the first trimester
cases should be confirmed serologically or
suggests high fetal risk; such women require
virologically.
counseling regarding therapeutic abortion.
Congenital rubella must be differentiated from
When pregnancy termination is not an option, some
congenital CMV infection, toxoplasmosis, and
experts recommend intramuscular administration of
syphilis.
20 mL of immune globulin within 72 hours after
Complications & Sequelae exposure in an attempt to prevent infection. (This
negates the value of subsequent antibody testing.)
A. Arthralgia and arthritis: The efficacy of this practice is unknown.
Both occur more often in adult women. Polyarticular Treatment & Prognosis:
involvement (fingers, knees, wrists), lasting a few
days to weeks, is typical. Frank arthritis occurs in a Symptomatic therapy is sufficient. Arthritis may
small percentage of patients. It may resemble acute improve with administration of anti-inflammatory
rheumatoid arthritis. agents. The prognosis is excellent in all children
and adults but poor in congenitally infected infants,
B. Encephalitis: in whom most defects are irreversible or
With an incidence of about 1:6000, this is a progressive. The severe cognitive defects seem to
nonspecific parainfectious encephalitis associated correlate closely in these infants with the degree of
growth failure.

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