Rubella, Emergency Medicine

Basics

Description

Also known as German measles or 3 " “day measles
Transmission via droplets from respiratory secretions
Moderately contagious:
- Especially during rash eruption and infants with congenital rubella syndrome (CRS)
Up to 50% may be subclinical.
Infants with congenital rubella shed large quantities of virus for several months.
Infectious period 7 days before to 5 days after appearance of rash
Incubation period: 14 " “21 days

Etiology

Rubella virus (family: Togaviridae, genus: Rubivirus)
Live, attenuated virus vaccine indications:
- All children >12 mo and entering school
- All women of childbearing age

Diagnosis

Signs and Symptoms

Acute viral disease
Complications:
- Uncommon, tend to occur more in adults
- CRS: Infected women in 1st trimester (hearing loss, mental retardation, cardiovascular defect, ocular defect)
- Arthritis:
  - More common in women (up to 79%)
  - Chronic arthritis is rare.
  - Begins after 2 " “3 days of illness
  - Knees, wrists, fingers affected
- Hemorrhagic manifestations:
  - Secondary to thrombocytopenia
  - More common in children
- Neurologic sequelae:
  - Encephalitis most common in adults; prognosis usually good
  - No causal relationship to autism

History

Low-grade fever
Malaise
Headache
Upper respiratory tract symptoms

Physical Exam

Rash:
- Rash is fainter than measles rash and does not coalesce.
- Red macular rash evolving to pink-red maculopapules with occasional pruritus
- Begins in face with rapid caudal spread
- Completed in 1st day and disappears in 3 days
- May have hemorrhagic manifestations
Lymphadenopathy:
- Postauricular
- Occipital
- Posterior cervical

Essential Workup

Generally clinical diagnosis ‚

Diagnosis Tests & Interpretation

Lab

CBC:
- Decreased WBC, platelets (more common in children)
Urinalysis:
- Hematuria
Reverse transcriptase " “polymerase chain reaction
ELISA to detect rubella IgM
Rubella antibody titer:
- Acute and convalescent serum specimens
- Hemagglutination-inhibition test most common
- Rubella specific IgM antibodies using enzyme immunoassay (EIA) commercially available. Detectable 4 days after onset of rash
- Definitive diagnosis in acute infection
- Compare infant with maternal sera for CRS.
- False positives in parvovirus, infectious mononucleosis, rheumatoid factor
- May be useful to check for immunity of pregnant patients with potential exposure.
Pharynx:
- Virus may be isolated from pharynx 1 wk before and until 2 wk after rash onset (valuable epidemiologic tool).
CSF:
- Few WBCs (monocytes) in encephalitis

Diagnostic Procedures/Surgery

Lumbar puncture if suspected encephalitis
Arthrocentesis in unexplained arthritis.

Differential Diagnosis

Scarlet fever:
- "Sandpaper " ť rash, Pastia lines, and strawberry tongue
Measles (rubeola):
- Koplik spots, cough, coryza, conjunctivitis, and fever
Roseola infantum:
- Spring and fall
Rocky Mountain spotted fever:
- Rash begins at ankles and wrists.
Rheumatoid arthritis

Treatment

Pre-Hospital

Use N95 filter mask for potential respiratory transmission. ‚

Initial Stabilization/Therapy

ABC management ‚

Ed Treatment/Procedures

Symptomatic therapy
Antipyretics and anti-inflammatory agents:
- Acetaminophen
- Ibuprofen
Isolate rubella patients from susceptible persons (e.g., pregnancy).
Vaccine:
- Measles, mumps, and rubella vaccine
- Rubella vaccine is live attenuated virus.
- Indications:
  - >12 mo and entry to school
  - Susceptible postpubertal females
  - High-risk groups (colleges, military, places of employment)
  - Unimmunized contacts
  - Healthcare workers and women of childbearing age born after 1957
  - Nonpregnant women may have arthralgia in up to 25%
- Contraindicated in pregnant women
- Avoid pregnancy for 3 mo after vaccination.
- 1 dose confers probable lifelong protection.
- Common complaints are fever, lymphadenopathy, and arthralgia.
Immunoglobulin:
- Will not prevent viremia but may modify symptoms

Medication

Acetaminophen: 500 mg (peds: 15 mg/kg/dose) PO q4h; do not exceed 5 doses/24 h or 4 g/24 h
Ibuprofen: 200 " “600 mg (peds: 5 " “10 mg/kg PO q6 " “8h); suspension 100 mg/5 mL; oral drops 40 mg/mL
Immunoglobulin: 0.5 mL reconstituted vial SC (0.25 " “0.50 mL/kg)

Follow-Up

Disposition

Admission Criteria

CRS
Encephalitis

Discharge Criteria

Most patients may go home.
Inquire regarding vaccination status of family members.

Issues for Referral

Potential exposure or disease in pregnant women
Complications
CRS-suspected child will need comprehensive evaluation.

Followup Recommendations

Pregnant women with suspected rubella or exposure must be followed with titers and counseling should have obstetric consult. ‚

Pearls and Pitfalls

Current literature does not support a causal relationship between childhood vaccination with thimerosal-containing vaccines and development of autism-spectrum disorders.
Infected individual should be isolated from susceptible (pregnancy, immunocompromised) individual for 7 days.

Additional Reading

American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 29th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.
Banatvala ‚ JE, Brown ‚ DW. Rubella. Lancet. 2004;363:1127 " “1137.
Gerber ‚ JS, Offit ‚ PA. Vaccines and autism: A tale of shifting hypotheses. Clin Infect Dis. 2009;48:456 " “461.
Mason ‚ WH. Rubella. In: Kliegman ‚ RM, Behrman ‚ RE, Jenson ‚ HB, et al., eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders; 2007:1337 " “1340.

Codes

ICD9

056.9 Rubella without mention of complication
647.50 Rubella in the mother, unspecified as to episode of care or not applicable
771.0 Congenital rubella
056.71 Arthritis due to rubella
056.00 Rubella with unspecified neurological complication
056.01 Encephalomyelitis due to rubella
056.79 Rubella with other specified complications
056.8 Rubella with unspecified complications

ICD10

B06.9 Rubella without complication
O35.3XX0 Maternal care for (suspected) damage to fetus from viral disease in mother, not applicable or unspecified
P35.0 Congenital rubella syndrome
B06.82 Rubella arthritis
B06.00 Rubella with neurological complication, unspecified
B06.01 Rubella encephalitis
B06.89 Other rubella complications

SNOMED

36653000 Rubella (disorder)
1857005 Congenital rubella syndrome (disorder)
84939004 Rubella in mother complicating pregnancy, childbirth AND/OR puerperium
19431000 Rubella arthritis (disorder)
186567003 Rubella with neurological complication (disorder)
240485004 Hemorrhagic rubella (disorder)

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