Pediatric Rubella Clinical Presentation

Updated: Feb 09, 2017
  • Author: Elias Ezike, MD; Chief Editor: Russell W Steele, MD  more...
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Presentation

History

Postnatal rubella

Rubella virus is transmitted from person to person via the aerosolized particles from the respiratory tract. A history of exposure may not be present. Individuals may acquire the infection from a completely asymptomatic patient or from an individual shedding the virus during the incubation period.

The incubation is usually 14-21 days after exposure to a person with rubella.

Prodromal symptoms are unusual in young children but are common in adolescents and adults.

The following signs and symptoms usually appear 1-5 days before the onset of rash:

  • Eye pain on lateral and upward eye movement (a particularly troublesome complaint)

  • Conjunctivitis

  • Sore throat

  • Headache

  • General body aches

  • Low-grade fever

  • Chills

  • Anorexia

  • Nausea

  • Tender lymphadenopathy (particularly posterior auricular and suboccipital lymph nodes)

  • Forchheimer sign (an enanthem observed in 20% of patients with rubella during the prodromal period; can be present in some patients during the initial phase of the exanthem; consists of pinpoint or larger petechiae that usually occur on the soft palate)

Congenital rubella

Congenital rubella history focuses on the following:

  • The number of weeks of pregnancy when maternal exposure to rubella occurred (The risk of congenital rubella syndrome is higher if maternal exposure occurs during the first trimester.)

  • Maternal history of immunization or medical history of rubella

  • Evidence of intrauterine growth retardation during pregnancy

  • Manifestations suggestive of congenital rubella syndrome in a child

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Physical

Physical findings are based on the type of rubella.

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Postnatal Rubella

Rash

The exanthem of rubella consists of a discrete rose-pink maculopapular rash ranging from 1-4 mm. See the image below.

Image in a 4-year-old girl with a 4-day history of Image in a 4-year-old girl with a 4-day history of low-grade fever, symptoms of an upper respiratory tract infection, and rash. Courtesy of Pamela L. Dyne, MD.

Rash in adults may be quite pruritic.

The synonym "3-day measles" derives from the typical course of rubella exanthem that starts initially on the face and neck and spreads centrifugally to the trunk and extremities within 24 hours. It then begins to fade on the face on the second day and disappears throughout the body by the end of the third day.

Temperature

Fever is usually not higher than 38.5°C (101.5°F).

Lymph nodes

Enlarged posterior auricular and suboccipital lymph nodes are usually found on physical examination.

Mouth

The Forchheimer sign may still be present on the soft palate.

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Congenital Rubella Syndrome

The classic triad presentation of congenital rubella syndrome consists of the following:

  • Sensorineural hearing loss is the most common manifestation of congenital rubella syndrome. It occurs in approximately 58% of patients. Studies have demonstrated that approximately 40% of patients with congenital rubella syndrome may present with deafness as the only abnormality without other manifestations. Hearing impairment may be bilateral or unilateral and may not be apparent until the second year of life.

  • Ocular abnormalities including cataract, infantile glaucoma, and pigmentary retinopathy occur in approximately 43% of children with congenital rubella syndrome. Both eyes are affected in 80% of patients, and the most frequent findings are cataract and rubella retinopathy. Rubella retinopathy consists of a salt-and-pepper pigmentary change or a mottled, blotchy, irregular pigmentation, usually with the greatest density in the macula. The retinopathy is benign and nonprogressive and does not interfere with vision (in contrast to the cataract) unless choroid neovascularization develops in the macula.

  • Congenital heart disease including patent ductus arteriosus (PDA) and pulmonary artery stenosis is present in 50% of infants infected in the first 2 months' gestation. Cardiac defects and deafness occur in all infants infected during the first 10 weeks of pregnancy and deafness alone is noted in one third of those infected at 13-16 weeks of gestation.

Other findings in congenital rubella syndrome include the following:

  • Intrauterine growth retardation, prematurity, stillbirth, and abortion

  • CNS abnormalities, including mental retardation, behavioral disorders, encephalographic abnormalities, hypotonia, meningoencephalitis, and microcephaly

  • Hepatosplenomegaly

  • Jaundice

  • Hepatitis

  • Skin manifestations, including blueberry muffin spots that represent dermal erythropoiesis and dermatoglyphic abnormalities

  • Bone lesions, such as radiographic lucencies

  • Endocrine disorders, including late manifestations in congenital rubella syndrome usually occurring in the second or third decade of life (eg, thyroid abnormalities, diabetes mellitus)

  • Hematologic disorders, such as anemia and thrombocytopenic purpura

Table 2. Clinicopathologic Abnormalities in Congenital Rubella (Open Table in a new window)

Abnormality

Common/Uncommon

Early/Delayed

Comment

General

Intrauterine growth retardation

Common

Early

...

Prematurity

Uncommon

Early

...

Stillbirth

Uncommon

Early

...

Abortion

Uncommon

Early

...

Cardiovascular system

Patent ductus arteriosus

Common

Early

May occur with pulmonary artery stenosis

Pulmonary artery stenosis

Common

Early

Caused by intimal proliferation

Coarctation of the aorta

Uncommon

Early

...

Myocarditis

Uncommon

Early

...

Ventricular septal defect

Uncommon

Early

...

Atrial septal defect

Uncommon

Early

...

Eye

Cataract

Common

Early

Unilateral or bilateral

Retinopathy

Common

Early

Salt-and-pepper appearance; visual acuity unaffected; frequently unilateral

Cloudy cornea

Uncommon

Early

Spontaneous resolution

Glaucoma

Uncommon

Early/Delayed

May be bilateral

Microphthalmia

Common

Early

Common in patients with unilateral cataract

Subretinal neovascularization

Uncommon

Delayed

Retinopathy with macular scarring and loss of vision

Ear

Hearing loss

Common

Early/Delayed

Usually bilateral; mostly sensorineural; may be central in origin; rare when maternal rubella occurs >4 months' gestation; sometimes progressive

CNS

Meningoencephalitis

Uncommon

Early

Transient

Microcephaly

Uncommon

Early

May be associated with normal intelligence

Intracranial calcifications

Uncommon

Early

...

Encephalographic abnormalities

Common

Early

Usually disappear by age 1 y

Mental retardation

Common

Delayed

...

Behavioral disorders

Common

Delayed

Frequently related to deafness

Autism

Uncommon

Delayed

...

Chronic progressive panencephalitis

Uncommon

Delayed

Manifest in second decade of life

Hypotonia

Uncommon

Early

Transitory defect

Speech defects

Common

Delayed

Uncommon in absence of hearing loss

Skin

Blueberry muffin spots

Uncommon

Early

Represents dermal erythropoiesis

Chronic rubelliform rash

Uncommon

Early

Usually generalized; lasts several weeks

Dermatoglyphic abnormalities

Common

Early

...

Lungs

Interstitial pneumonia

Uncommon

Delayed

Generalized; probably immunologically mediated

Liver

Hepatosplenomegaly

Common

Early

Transient

Jaundice

Uncommon

Early

Usually appears in the first day of life

Hepatitis

Uncommon

Early

May not be associated with jaundice

Blood

Thrombocytopenia

Common

Early

Transient; no response to steroid therapy

Anemia

Uncommon

Early

Transient

Hemolytic anemia

Uncommon

Early

Transient

Altered blood group expression

Uncommon

Early

...

Immune system

Hypogammaglobulinemia

Uncommon

Delayed

Transient

Lymphadenopathy

Uncommon

Early

Transient

Thymic hypoplasia

Uncommon

Early

Fatal

Bone

Radiographic lucencies

Common

Early

Transient; most common in distal femur and proximal tibia

Large anterior fontanel

Uncommon

Early

...

Micrognathia

Uncommon

Early

...

Endocrine glands

Diabetes mellitus

Common

Delayed

Usually becomes apparent in second or third decade of life

Thyroid disease

Uncommon

Delayed

Hypothyroidism, hyperthyroidism, and thyroiditis

Growth hormone deficiency

Uncommon

Delayed

...

Genitourinary system

Cryptorchidism

Uncommon

Early

...

Polycystic kidney

Uncommon

Early

...

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Causes

Rubella and congenital rubella syndrome are caused by rubella virus. Only one antigenic type of rubella virus is available, and humans are the only natural hosts. The virus is spherical with a diameter of 50-70 nm, has a central core (ie, nucleocapsid), and is covered externally by a lipid-containing envelope. The nucleocapsid is composed of polypeptide (C protein) and a single-stranded RNA.

Its outer envelope is made up of glycosylated lipoprotein, which contains 2 virus-specific polypeptides (E1, E2) and a host-cell–derived lipid. These 2 envelope proteins comprise the spiked 5-nm to 6-nm surface projections that are observed on the outer membrane of rubella virus and are important for the virulence of the virus.

Monoclonal antibodies directed against epitopes of E1 and E2 have neutralizing activity. Protein E1 is the viral hemagglutinin that binds both hemagglutination-inhibiting and hemolysis-inhibiting antibodies.

Rubella virus is rapidly inactivated by 70% alcohol, ethylene oxide, formalin, ether, acetone, chloroform, free chlorine, deoxycholate, beta-propiolactone, ultraviolet light, extreme pH (< 6.8 or >8.1), heat (>56°C), and cold (from -10°C to -20°C). It is resistant to thimerosal and is stable at temperatures of -60°C or less.

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