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Key Features

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Essentials of Diagnosis
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  • History of rubella vaccination usually absent

  • Fever with postauricular and occipital adenopathy

  • Maculopapular rash beginning on face, rapidly spreading to the entire body, and disappearing by fourth day

  • Congenital infection

    • Retarded growth and development

    • Cataracts, retinopathy

    • Purpuric "blueberry muffin" rash at birth

    • Jaundice, thrombocytopenia

    • Deafness

    • Congenital heart defect

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General Considerations
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  • Causes a mild, self-limited exanthema (over 80% of infections are subclinical)

  • However, infection during pregnancy leads to teratogenicity and miscarriage

  • Endemic rubella is absent in the United States and the Americas

  • Congenital rubella in infants born to unimmunized women and the occasional woman who is reinfected in pregnancy, is very rare

  • Sporadic cases occur in immigrants to the United States from Asia and Africa

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Clinical Findings

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Symptoms and Signs
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  • Incubation period is 14–21 days

  • Transmitted by aerosolized respiratory secretions

  • Patients are infectious 5 days before until 5 days after the rash

  • Infection in children

    • Young children may only have rash

    • Rash consists of erythematous discrete maculopapules beginning on the face and spreading to the trunk and extremities within 24 hours

    • Older patients often have a nonspecific prodrome of low-grade fever, ocular pain, sore throat, and myalgia

    • Postauricular and suboccipital adenopathy (sometimes generalized) is characteristic

  • Congenital infection

    • More than 80% of women infected in the first 4 months of pregnancy (25% near the end of the second trimester) deliver an affected infant

    • Congenital disease occurs in < 5% of women infected later in pregnancy

    • Later infections can result in isolated defects, such as

      • Growth retardation

      • Cardiac anomalies (pulmonary artery stenosis, patent ductus arteriosus, ventricular septal defect)

      • Ocular anomalies (cataracts, microphthalmia, glaucoma, retinitis)

      • Deafness (sensorineural)

      • Cerebral disorders (chronic encephalitis, retardation)

      • Hematologic disorders (thrombocytopenia, dermal nests of extramedullary hematopoiesis or purpura ("blueberry muffin" rash), lymphopenia

      • Hepatitis, osteomyelitis, immune disorders, malabsorption, diabetes

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Differential Diagnosis
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  • Measles

  • Enterovirus

  • Adenovirus

  • Epstein-Barr virus

  • Roseola

  • Parvovirus

  • Toxoplasma gondii infection

  • Drug reactions

  • Congenital cytomegalovirus infection, toxoplasmosis, and syphilis

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Diagnosis

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Laboratory Findings
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  • Leukopenia is common

  • Platelet counts may be low

  • Congenital infection

    • Associated with low platelet counts, abnormal liver function tests, hemolytic anemia, and CSF pleocytosis

    • Virus may be isolated from oral secretions or urine from 1 week before to 2 weeks after onset of rash

    • Children are infectious for months

    • Direct RNA amplification (PCR) is common and very sensitive

    • Serologic immunoassay diagnosis is best made by demonstrating a fourfold rise in antibody titer between specimens drawn 1–2 weeks apart

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Imaging
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  • Radiography: Pneumonitis and bone metaphyseal longitudinal lucencies may be present in children with congenital infection

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Treatment

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  • Symptomatic therapy is sufficient

  • Arthritis may improve with administration of anti-inflammatory agents

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Outcome

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Prevention
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  • A pregnant woman possibly exposed to rubella should be tested immediately

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