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Rubella, Emergency Medicine

Basics

Description

- 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

- Neurologic sequelae: - Encephalitis most common in adults; prognosis usually good - No causal relationship to autism

- 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

- Urinalysis: - 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.

- Symptomatic therapy - Antipyretics and anti-inflammatory agents: - 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%

  • 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 schoolAll women of childbearing age

Diagnosis

Signs and Symptoms

  • Acute viral disease
  • Complications:Uncommon, tend to occur more in adultsCRS: 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 illnessKnees, wrists, fingers affectedHemorrhagic manifestations:Secondary to thrombocytopeniaMore common in childrenNeurologic sequelae:Encephalitis most common in adults; prognosis usually goodNo 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 pruritusBegins in face with rapid caudal spreadCompleted in 1st day and disappears in 3 daysMay have hemorrhagic manifestations
  • Lymphadenopathy:PostauricularOccipitalPosterior cervical

Essential Workup

Generally clinical diagnosis ‚

Diagnosis Tests & Interpretation

Lab

  • CBC:Decreased WBC, platelets (more common in children)
  • Urinalysis:
  • Reverse transcriptase " “polymerase chain reaction
  • ELISA to detect rubella IgM
  • Rubella antibody titer:Acute and convalescent serum specimensHemagglutination-inhibition test most commonRubella specific IgM antibodies using enzyme immunoassay (EIA) commercially available. Detectable 4 days after onset of rashDefinitive diagnosis in acute infectionCompare infant with maternal sera for CRS.False positives in parvovirus, infectious mononucleosis, rheumatoid factorMay 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:
  • 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:
  • Isolate rubella patients from susceptible persons (e.g., pregnancy).
  • Vaccine:Measles, mumps, and rubella vaccineRubella vaccine is live attenuated virus.Indications:>12 mo and entry to schoolSusceptible postpubertal femalesHigh-risk groups (colleges, military, places of employment)Unimmunized contactsHealthcare workers and women of childbearing age born after 1957Nonpregnant women may have arthralgia in up to 25%Contraindicated in pregnant womenAvoid 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

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)