MM 499-502; ID 903-911
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NAME OF DISEASE:     Rubella
                                        German measles
                                        Three-day measles


    The rubella virus (a togavirus), contains RNA and an envelope. It replicates in the cytoplasm.


    Man is only host. Disease is spread by droplet inhalation. Attack rate is highest in five-nine year age group but is also high in older children and adolescents and in adults up to 35 years of age.


    Incubation period is 18 days. The virus initially replicates in the upper respiratory tract mucosa and in cervical lymph nodes. After multiplication at these sites, the virus is disseminated to other parts of the body through the blood. Viremia can be detected as early as 9 days before the exanthem. During this period or shortly thereafter, enlargement of the cervical lymph nodes commonly appears. Coincident with development of the rash, or within 24-48 hours, neutralizing antibodies become detectable and circulating virus disappears from the blood. The exanthem represents an inflammatory effect exerted by an antibody-virus complex, rather than direct viral invasion of the vascular epithelium. Since the disease is mild, few histological studies have been done; nonspecific acute and chronic inflammatory changes have been described in the skin and affected lymph nodes.


    1.     Encephalitis (1/6000 cases). More common in children. Occurs one-seven days after rash.
            CSF may contain up to 300 cells, mostly monocytes. Sugar and protein normal. EEG
            abnormalities may persist for months or years.

    2.     Arthritis (33% of adult women). Appears with rash or within three days of it, most
            frequently involving the fingers, wrists and knees. Tests for rheumatoid factor may be
            positive. Lasts 2-30 days. Self limited.

    3.     Hemorrhagic manifestations (rare). Begins abruptly three-four days after onset of the rash.
            The skin and the mucous membranes are the most common sites of bleeding.


    The clinical diagnosis of rubella may be made with assurance only in typical cases occurring during an epidemic. The large number of atypical and subclinical cases of rubella, together with the numerous conditions of an infectious or allergic nature that may be associated with a rubelliform rash, make the clinical diagnosis difficult. The stages of the disease are:

    1.     Incubation period (18 days). Virus is replicating in mucosa and lymph nodes and viremia
            occurs. Lymph nodes become enlarged.

    2.     Prodromal stage (one-five days before rash). A mild prodromal period may occur but this is
            often absent in young children. It is characterized by anorexia (loss of appetite), malaise,
            conjunctivitis, headache, and minimal respiratory symptoms. Enlarged tender lymph nodes
            four-ten days before rash. Viremia is evident.

    3.     Exanthem. As the prodromal symptoms diminish, the rash appears. The exanthem consists
            of a discrete, pink, maculopapular eruption that begins on the face, spreads rapidly
            downward, over the trunk and extremities, often within hours, and fades in the same order
            in which it evolved. By the end of the second day, the face may be clearing and previous
            discrete rash on the trunk may be nearly confluent. At this stage, rubella is often confused
            with scarlet fever, although the exanthem usually remains discrete on the extremities. The
            rash may persist four-five days but it generally disappears by the end of the third day. The
            rash is non-blanching and does not appear on the palms and soles. A low grade fever may
            accompany the rash. Forchheimer spots consisting of small, red macules on the soft
            palate, often precede or accompany the rash. These are not diagnostic as they also appear
            in scarlet fever, roseola, infectious mononucleosis and septicemia. Neutralizing antibodies
            become detectable coincident with the rash and generally last a lifetime.


    An attenuated live rubella virus vaccine is currently available. Administer to children between the ages of one and puberty. Because the effect of vaccine virus on the human fetus is unknown, susceptible women of childbearing age should be vaccinated only when extreme precautions have been taken to prevent pregnancy before and during the two months after administration of the vaccine. The vaccine is usually a trivalent one consisting of measles-mumps-rubella (MMR vaccine) and is given in a single injection at 15 months of age.


    In 1941, after an epidemic of rubella in Australia, it was noted that children born of mothers who had rubella during the first trimester of pregnancy exhibited certain unique features:

                              )     1.     Small and ill-nourished (low-birth weight)
       Congenital       )     2.     Congenital cataracts and glaucoma
                              )     3.     Congenital heart disease
       rubella             )     4.     Mental retardation
                              )     5.     Deafness
       syndrome        )     6.     Purpura


    1.     History of rubella during first trimester of pregnancy.

    2.     Isolation of rubella virus from fluid obtained by amniocentesis.

    3.     Presence of rubella IgM antibodies during the first six months of age.

    4.     Presence of IgG rubella antibodies after six months of age.

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