Updated: 1/26/2022

Rubella (German Measles)

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  • Snapshot
    • A 30-year-old woman presents to the emergency room. She is a tourist from Southeast Asia and reports having a low-grade fever for several days. She also reports having arthralgias, especially in her wrists and knees. Additionally, she has a pink rash on her face and her chest. The rash appears to be spreading downward. She does not recall whether or not she had the measles, mumps, and rubella vaccine. On physical exam, she has lymphadenopathy in her postauricular and posterior cervical chains. She also has petechiae on her soft palate and uvula and a pink maculopapular rash on her face and trunk. Isolation precautions are indicated.
  • Introduction
    • Classification
      • rubella virus
        • an enveloped, icosahedral capsid, single-stranded, positive-sense RNA virus
        • a togavirus
        • causes rubella (German (3-day) measles)
        • transmission via respiratory secretions
    • Prevention
      • measles, mumps, and rubella (MMR) vaccine
        • given over 2 doses
  • Epidemiology
    • Incidence
      • decreased in the US due to vaccination
      • endemic in other parts of the world
    • Demographics
      • any age can be affected
    • Risk factors
      • lack of vaccination
      • travel to or from endemic areas
  • ETIOLOGY
    • Pathogenesis
      • the virus replicates in the upper respiratory tract and lymph nodes
      • it then disseminates throughout the body
      • can spread through the placenta to cause vertical transmission
        • may result in miscarriage or congenital rubella syndrome
    • Associated conditions
      • congenital rubella syndrome
        • blueberry muffin appearance
          • dermal extramedullary hematopoiesis
        • cataracts
        • deafness
        • congenital heart disease
  • Presentation
    • Symptoms
      • low-grade fever
      • polyarthritis and polyarthralgia
        • more common in adult females
        • fingers, wrists, and knees are most commonly involved
    • Physical exam
      • lymphadenopathy before the rash
        • postauricular lymphadenopathy is classic
        • may also have posterior cervical and suboccipital lymphadenopathy
      • fine, pink, non-confluent maculopapular rash
        • starts on face and spreads to trunk and extremities
        • may be itchy
        • desquamates
        • rash resolves in 3 days
      • petechial rash on soft palate (Forschheimer spots)
      • orchitis
  • Studies
    • Labs
      • detection of rubella-specific immunoglobulin M or G
      • detection of virus on reverse transcriptase-polymerase chain reaction
  • Differential
    • Parvovirus B19 infection
      • distinguishing factors
        • slapped cheek rash
        • maculopapular rash on trunk and limbs that does not spread from head/neck downward
    • Measles
      • distinguishing factors
        • confluent maculopapular rash
        • coryza and Koplik spots
  • DIAGNOSIS
    • Making the diagnosis
      • based on clinical presentation and confirmed with laboratory studies
  • Treatment
    • Management approach
      • mainstay of treatment is supportive care and prevention with vaccines
    • Conservative
      • supportive care
        • indication
          • all patients
        • modalities
          • antipyretics
          • analgesics
          • hydration
  • Complications
    • Vertical transmission to fetus
      • congenital rubella syndrome
    • Thrombocytopenic purpura
    • Guillain-Barre syndrome
  • Prognosis
    • Infection may be asymptomatic but still contagious
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(M2.PD.14.35) A 7-year-old boy presents to an urgent care center for a rash that began approximately 2 days ago. According to his mother, it began as a pink rash on his face and has subsequently spread to his trunk. The child was adopted and has not yet begun care with his pediatrician. His temperature is 100.2°F (37.9°C), blood pressure is 104/74 mmHg, pulse is 99/min, respirations are 19/min, and oxygen saturation is 99% on room air. Physical exam is notable for the rash in Figure A and posterior auricular lymphadenopathy. The child is otherwise interactive and is quietly playing with toys. Which of the following is the most likely diagnosis?

QID: 104246
FIGURES:

Kawasaki disease

3%

(1/39)

Parvovirus

18%

(7/39)

Rubella

67%

(26/39)

Rubeola

8%

(3/39)

Roseola

3%

(1/39)

M 6 E

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