History

Fact Explanation
Rash Rubella (German measles) is commonly a mild disease characterized by a rash.It affects children and adolescents and can also affect young adults. The maculopapular rash appears first on the face and neck and quickly spreads to the trunk and upper extremities and then to the legs. While progressing downwards, it fades on the face. Lesions are discrete at first, but rapidly coalesce to produce a flushed appearance.Rash usually lasts 3 to 5 days.[3].
Fever Postnatal rubella is often asymptomatic but may result in a generally mild, self-limited illness. They may get low grade fever. Usually the onset of rash is often accompanied by low-grade fever. Even though the rash lasts about 3 to 5 days,associated fever rarely persists for more than 24 hours.[3].
Headache Adolescents and adults may experience headache as a typical mild prodromal symptom.Usually not seen in infected children.Occurs 1 to 5 days before the rash. Other features include fever and malaise.[3].
Arthralgia and Arthritis Rubella can cause complications, associated with transient joint involvement such as arthritis and arthralgia being the most frequent. Usually these symptoms are more prevalent and severe in RV-infected women than in RV-infected men.[4]. Symptoms begin with in one week of the appearance of rash.[5]. This etiological association is suspected due to detection of rubella virus from peripheral blood or synovial fluid lymphocytes of affected joints and detection of viral antigen in synovial fluid.But little is known concerning host response to rubella virus and the mechanisms by which this virus has exerts its arthritogenic potential in vivo. [1].
Post infectious encephalopathy / encephalomyelitis Post infectious encephalopathy or encephalomyelitis are very occasionally associated with postnatally acquired rubella.[4]. This is known to be developed abruptly after the fading of exanthem.The pathogenesis of post rubella neurogenic complications is not completely understood. But two different mechanisms including direct invasion of the virus and host immune response has been observed.[2].
Stillbirth Rubella infection acquired during pregnancy can result in stillbirth and also spontaneous abortion.[3]. Microscopic analyses of aborted infected fetuses revealed cellular damage in multiple sites.It was associated with non inflammatory necrosis commonly in the structures of the eyes, heart, brain, and ears of aborted RV infected fetuses.[4].
Progressive rubella panencephalitis A rare and usually fatal neurodegenerative disorder termed progressive rubella panencephalitis has also been reported as a late complication of childhood rubella.[4]. It is a recently recognized inflammatory disorder of CNS that appears to be a delayed reactivation of congenital rubella and postnatal rubella infection. Neurological deterioration begins with dementia and gait disturbance in the second decade and leads to death with in several years.[6].
References
  1. TINGLE AJ, YANG T, ALLEN M, KETTYLS GD, LARKE RP, SCHULZER M. Prospective Immunological Assessment of Arthritis Induced by Rubella Vaccine Infect Immun [online] 1983 Apr, 40(1):22-28 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC264812
  2. CHANG DI, PARK JH, CHUNG KC. Encephalitis and polyradiculoneuritis following rubella virus infection--a case report. J Korean Med Sci [online] 1997 Apr, 12(2):168-170 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3054242
  3. PARKMAN PD, BARON S. Togaviruses: Rubella Virus [online] 1996 [viewed 31 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21413314
  4. LEE JY, BOWDEN DS. Rubella Virus Replication and Links to Teratogenicity Clin Microbiol Rev [online] 2000 Oct, 13(4):571-587 [viewed 02 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88950
  5. TINGLE AJ, ALLEN M, PETTY RE, KETTYLS GD, CHANTLER JK. Rubella-associated arthritis. I. Comparative study of joint manifestations associated with natural rubella infection and RA 27/3 rubella immunisation. Ann Rheum Dis [online] 1986 Feb, 45(2):110-114 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1001829
  6. WOLINSKY JS, DAU PC, BUIMOVICI-KLEIN E, MEDNICK J, BERG BO, LANG PB, COOPER LZ. Progressive rubella panencephalitis: immunovirological studies and results of isoprinosine therapy. Clin Exp Immunol [online] 1979 Mar, 35(3):397-404 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1537624

Examination

Fact Explanation
Lymphadenopathy Lymphadenopathy can be characteristic, involving the posterior cervical and occipital nodes, which can persist after the rash has resolved.[4]. The virus almost certainly multiplies in cells of the respiratory tract, extends to local lymph nodes, and then undergoes viremic spread to target organs. Subsequent additional replication is seen in selected target organs, such as the spleen and lymph nodes.[3].
Conjunctivitis In some patients rubella rash accompanied by mild bulbar conjunctivitis.The rubella virus agent is probably acquired through the droplets entering the upper respiratory tract but it can also enter by conjunctiva.[2].
Thrombocytopenic purpura More serious complications that are occasionally associated with postnatally acquired rubella.[4]. Widely known and frequently diagnosed following rubella.Purpura may be fulminating and may occur at the height of the febrile illness.The time interval between the exanthema and the detection of virus may vary from a week to months.[1].
Congenital rubella syndrome (CRS) in infants. Maternal infection early in pregnancy leads to the congenital rubella syndrome (CRS) in infants. Infection in the early gestation period causes more severe damage to the fetus. Maternal infection during the first 8 weeks after the last menstrual period results in nearly all fetuses becoming infected. And also up to 100% of infected fetuses developing congenital defects.The clinical manifestations of CRS are varied. Deafness being the most common. Other clinical features include cardiac disease, mental retardation, and ocular conditions such as cataracts and glaucoma. Those complications occurred due to its teratogenicity in maternal infection.[4].
References
  1. SLADDEN RA. Thrombocytopenic Purpura and Rubella Br Med J [online] 1963 Dec 21, 2(5372):1587-1588 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873823
  2. KIBRICK S. RUBELLA AND RUBELLIFORM RASH Bacteriol Rev [online] 1964 Dec, 28(4):452-457 [viewed 01 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC441245
  3. PARKMAN PD, BARON S. Togaviruses: Rubella Virus [online] 1996 [viewed 02 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21413314
  4. LEE JY, BOWDEN DS. Rubella Virus Replication and Links to Teratogenicity Clin Microbiol Rev [online] 2000 Oct, 13(4):571-587 [viewed 02 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88950

Differential Diagnoses

Fact Explanation
Measles Associated with maculopapular eruptions. Distinguishing features in this include, koplik spots, shorter incubation period, and a more severe primary respiratory prodrome.[1]. Headache, malaise and coryza are the other associated symptoms. Measles rash also begins upon the forehead and spread downward.[2]. Rash tends to be confluent on the face associated with brownish staining and fine desquamation of the affected skin during convalescence.[1].
Scarlet fever Rash of the scarlet fever also similar to rubella[1]. However this rash does not usually appears on the face as a rule.[2]. On the face rash is replaced by confluent erythema and circumoral pallor.[1]. Rash appears first in the neck and then spread above downwards. Rash is composed of firm red points on the background erythema. Later there is a bright general redness and the skin may be swollen. The flexures may show additional hemorrhagic staining of the skin. This is never found in rubella.[2]. The rash of scarlet fever desquamate in flakes and sheets.[1]. Rash is long lasting and may take several days to fade. Sore throat is a predominant feature of scarlet fever[2], with characteristic changes on the tongue.[1]. Cervical lymphadenopathy and increase WBC count can be seen.[1].
Erythema Infectiosum Maculopapular rash.The eruptions appears first on the cheeks as a bright red raised area of erythema, so called slapped face appearance. It persists for several days.Then symmetrically distributed maculopapular rash appears on the extremities. It appears lesser in concentration on the trunk. Rash persists about 2 weeks and may reappear after exercise, skin irritation or various other stimuli.[1].
Infectious Mononucleosis (IMN) Here the rash is inconstant and variable but may occasionally resembles rubella. In that case early differentiation is bit difficult because both diseases will show atypical lymphocytes and lymphadenopathy. Occurrence of membranous tonsillitis and the presence of characteristic laboratory features more suggestive of IMN.[1].
Drug sensitivity This may also leads to maculopapular eruptions closely resembling rubella. But there is no prodrome or adenopathy. And the course of rash is differ from rubella.In addition there will be a history of drug ingestion or exposure.[1].
References
  1. KIBRICK S. RUBELLA AND RUBELLIFORM RASH Bacteriol Rev [online] 1964 Dec, 28(4):452-457 [viewed 01 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC441245
  2. WARRACK JS. THE DIFFERENTIAL DIAGNOSIS OF SCARLET FEVER, MEASLES, AND RUBELLA Br Med J [online] 1918 Nov 2, 2(3018):486-488 [viewed 01 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2342078

Investigations - for Diagnosis

Fact Explanation
Full blood count As in many other viral diseases White blood cell count (WBC) range from low to normal.Frequently the number of atypical lymphocytes is increased.[1].
Viral isolation from clinical specimen Rubella virus has been regularly demonstrated in pharyngeal secretions for 5 days and feces for 4 days after onset of rash.It has been sporadically recovered from pharyngeal and rectal swabbing for 14 and 8 days respectively after beginning of the eruption and as long as one week prior to the rash.[1]. Virus can be readily recovered in cell cultures from respiratory tract secretions and, in infants with congenital infection, from urine, cerebrospinal fluid, and blood. Presence of virus in inoculated cultures can be recognized by viral interference or immunoperoxidase staining assays. But virus isolation procedures are costly and require a relatively sophisticated virologic laboratory.Because of that they are seldom used except for the diagnosis of congenital rubella.[2].
ELISA A serological assay (ELISA) can be easily and quickly performed to detect the presence rubella-specific antibodies. IgM is detectable within 7 to 10 days following the initial exanthema. False-positives may occur if the patient has a positive Rh factor, is infected with parvovirus, or has a positive heterophile test for infectious mononucleosis. Seven to 21 days after the first ELISA, they should obtain an additional ELISA to confirm the diagnosis. Infection can be confirmed by a positive IgM, a fourfold rise in IgG, or a positive culture.[3]
References
  1. KIBRICK S. RUBELLA AND RUBELLIFORM RASH Bacteriol Rev [online] 1964 Dec, 28(4):452-457 [viewed 01 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC441245
  2. PARKMAN PD, BARON S. Togaviruses: Rubella Virus [online] 1996 [viewed 01 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21413314
  3. WHITE SJ, BOLDT KL, HOLDITCH SJ, POLAND GA, JACOBSON RM. Measles, Mumps, and Rubella Clin Obstet Gynecol [online] 2012 Jun, 55(2):550-559 [viewed 05 August 2014] Available from: doi:10.1097/GRF.0b013e31824df256

Investigations - Screening/Staging

Fact Explanation
CSF (cerebrospinal fluid ) examination Should be examined in all suspected patients to exclude purulent meningitis.[1].
Amniocentesis, Cordocentesis, or Chorionic villus sampling If obstetric patient is positive for rubella infection, rubella may be diagnosed in the fetus by collecting either a specimen of amniotic fluid, cord blood, or placental tissue by amniocentesis, cordocentesis, or chorionic villus sampling (respectively) for use in laboratory assays. These laboratory assays include PCR, fluorescence, in situ hybridization, or ELISA (to quantify rubella-specific IgM).[2].
References
  1. CANTWELL RJ. Rubella Encephalitis Br Med J [online] 1957 Dec 21, 2(5059):1471-1473 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1962912
  2. WHITE SJ, BOLDT KL, HOLDITCH SJ, POLAND GA, JACOBSON RM. Measles, Mumps, and Rubella Clin Obstet Gynecol [online] 2012 Jun, 55(2):550-559 [viewed 05 August 2014] Available from: doi:10.1097/GRF.0b013e31824df256

Management - General Measures

Fact Explanation
Supportive care There is no specific treatment for rubella.Treatment consists of supportive care. Supportive therapy to address nutritional status, hemorrhagic complications, and secondary infections is therefore essential to optimize treatment outcomes.[1].
References
  1. KOUBâA M, MARRAKCHI C, MâALOUL I, MAKNI S, BERRAJAH L, ELLOUMI M, HAMMAMI B, LAHIANI D, BOUDAWARA T, BEN JEMâA M. Rubella Associated with Hemophagocytic Syndrome. First Report in a Male and Review of the Literature Mediterr J Hematol Infect Dis [online] , 4(1):e2012050 [viewed 02 August 2014] Available from: doi:10.4084/MJHID.2012.050

Management - Specific Treatments

Fact Explanation
Immunoglobulin There are no specific chemotherapeutic measures available for the treatment of rubella. Immunoglobulin has been used in attempts to prevent rubella in pregnant women exposed to the virus.[1]. Intramuscular administration of immune globulin (20 ml, given at two injection sites) within 72 hours of exposure may be administered to the obstetric patient to suppress, but not eliminate, symptoms. Infants with CRS have been born to women who received immune globulin therapy soon after exposure. So it is not a routine prophylaxis and should only be administered if the patient chooses not to terminate her pregnancy. Otherwise, treatment is limited to symptomatic relief.[4].
Vaccination Use to control the spread of the disease. Rubella can be prevented by routine childhood immunization and by immunization of susceptible adolescents and adult populations with live attenuated rubella vaccine. It induced immunity by producing a modified rubella infection in susceptible recipients. It is administered subcutaneously.[1]. MMR vaccine is used. Current recommended schedule is to receive the first dose at 12-15 months followed by the second dose at 4-6 years (before elementary school enrollment). In non pregnant women asked not to get pregnant for at least 28 days following the MMR vaccine series because of the theoretical risk posed by the live albeit attenuated vaccine viruses.[4]. However the anti-rubella vaccination represent the only way to prevent serious complications thus it should be indicated either in boys.[3].
References
  1. PARKMAN PD, BARON S. Togaviruses: Rubella Virus [online] 1996 [viewed 02 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21413314
  2. LEE JY, BOWDEN DS. Rubella Virus Replication and Links to Teratogenicity Clin Microbiol Rev [online] 2000 Oct, 13(4):571-587 [viewed 02 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88950
  3. KOUBâA M, MARRAKCHI C, MâALOUL I, MAKNI S, BERRAJAH L, ELLOUMI M, HAMMAMI B, LAHIANI D, BOUDAWARA T, BEN JEMâA M. Rubella Associated with Hemophagocytic Syndrome. First Report in a Male and Review of the Literature Mediterr J Hematol Infect Dis [online] , 4(1):e2012050 [viewed 02 August 2014] Available from: doi:10.4084/MJHID.2012.050
  4. WHITE SJ, BOLDT KL, HOLDITCH SJ, POLAND GA, JACOBSON RM. Measles, Mumps, and Rubella Clin Obstet Gynecol [online] 2012 Jun, 55(2):550-559 [viewed 05 August 2014] Available from: doi:10.1097/GRF.0b013e31824df256