AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Rubella is now rare because of widespread compliance with childhood immunization programs. The disease is usually a benign and inconsequential viral illness unless exposure occurs in utero.

Congenital rubella syndrome is associated with clinically significant congenital malformations. The live-attenuated virus vaccine has decreased the incidence of rubella significantly, thereby decreasing congenital disease.

Pathophysiology

The causative organism is a single-stranded RNA togavirus that is transmitted by means of respiratory droplets. The virus replicates in the nasopharynx and regional lymph nodes, resulting in viremia. The virus then may spread to the skin, CNS, synovial fluid, and transplacentally to a developing fetus.

Frequency

United States

Before the rubella vaccination became available in 1969, epidemics occurred every 6-9 years and pandemics every 10-20 years. In 1977-1981, 20,395 cases of rubella were reported in the United States. According to Statistical Handbook on Infectious Disease regarding historical trends of rubella in the United States, the incidence has significantly decreased since that time. In 1990, 1124 cases of rubella occurred, and in 1999, only 267 occurred. In the last decade, the rate has been less than 10 cases of congenital rubella syndrome per year. These cases mostly affected mothers born outside of the United States in Latin American countries with lower vaccination rates.

In 2004, the Centers for Disease Control and Prevention (CDC) reported that, since 2001, fewer than 25 cases of rubella have occurred each year in the United States.¹ The CDC estimates 95% vaccination coverage among school-aged children and 91% immunity in the population.¹

During the 1990's resistance to the MMR vaccine developed. An earlier (since discontinued) version in the UK was associated with aseptic meningitis. As a result of this, vaccination rates in the UK fell from an earlier level of 92% to 79% in 1998; they have since rebounded.² Moreover, a correlation between autism and MMR use was later postulated. Subsequent epidemiologic studies have shown no significant association between the vaccine and either condition. Vaccination rates remain very high in the United States; should this change in the future, the frequency of rubella could change dramatically.

International

The rubella vaccination is given to only about half the world's population. Congenital rubella syndrome remains a major problem in some areas. In Russia, for instance, congenital rubella syndrome causes 15% of all birth defects.

Mortality/Morbidity

Infection in healthy children or young adults is generally self-limited and without sequelae.

• The most common complications are arthropathies of the fingers, wrists, and knees that can persist for a year or more.
• Thrombocytopenia with purpura and hemorrhage is a rare complication of rubella.
• Congenital rubella syndrome is associated with malformations of multiple organ systems including the CNS and cardiac, ocular, and skeletal systems. Infants with congenital rubella syndrome who survive into adulthood may be plagued by autoimmune disorders and dysgammaglobulinemia. 
• Damage to the fetus is most likely when maternal infection occurs during the first 2 months of pregnancy, although there is risk associated with infection up to 5 months.

Race

• The highest risk is among members of racial or ethnic groups who are unvaccinated and who may be exposed to persons traveling from areas where rubella vaccination is not routine.
• Recent outbreaks have occurred among persons of Hispanic ethnicity. Consequently, Hispanic persons and persons from countries without rubella vaccination programs should be considered susceptible to rubella unless they have documentation of vaccination or serologic evidence of immunity.

Sex

Rubella affects men and women equally.

Age

Before vaccination, the peak incidence occurred in children aged 5-14 years. However, at present, most cases occur in teenagers or young adults.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

• The incubation period is 14-23 days.
• The prodrome is characterized by the following:
• • Malaise
  • Fever
  • Anorexia
  • Headache
  • Mild conjunctivitis
  • Rhinorrhea
• The rash develops within 1-5 days of symptom onset, starting on the face and forehead and spreading caudally to involve the trunk and extremities.
• • The rash tends to clear in the same order as it appeared.
  • The rash may be pruritic, but it usually resolves within 3 days without residua.

Physical

• Lymphadenopathy may be present, particularly in the posterior auricular, posterior cervical, and suboccipital chains.
• The rash consists of pink macules and papules, which may become confluent, resulting in a scarlatiniform eruption.
• Petechiae of the soft palate, known as the Forchheimer sign, may be present.

Causes

Rubella is caused by a single-stranded RNA togavirus.

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Lab Studies

• The diagnosis of rubella is clinical, though seroconversion in response to rubella antigens may confirm it.
• • Antibodies are often present shortly after the rash appears and increase in titer during the next 2-3 weeks.
  • Elevated levels of immunoglobulin M (IgM) antibodies are particularly helpful findings in newborns. IgM antibodies do not cross the placenta and indicate a recent infection acquired after birth.
• The rubella virus can potentially be isolated from a throat culture during the acute phase of illness, but this technique is not a practical way to establish the diagnosis.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Emergency Department Care

No antiviral therapy is available. Treatment is supportive.

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Antipyretics

These agents may be used to decrease fever. 

Drug Name	Ibuprofen (Motrin, Advil)
Description	NSAID that inhibits cyclooxygenase, inhibiting formation of prostaglandins.
Adult Dose	200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose	6 months to 12 years: 5 mg/kg/dose PO q6-8h prn for temperature <102.5°F; 10 mg/kg/dose PO q6-8h prn for temperature >102.5°F; not to exceed 40 mg/kg/d >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Category: Antihistamines

May be used to control itching.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Outpatient Care

• Arrange follow-up care with the patient's primary physician.

Deterrence/Prevention

• As a physician, emphasizing the safety of the MMR vaccine to patients is important. 

Prognosis

• Beyond the fetal period, rubella is generally benign and self-limiting and without complications.
• Infants born with congenital rubella syndrome may have a variety of complications; therefore, their prognosis depends on the severity of their malformations.

Patient Education

• Reinforcement of scheduled routine immunizations is imperative.
• For excellent patient education resources, visit eMedicine's Children's Health Center and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Measles; Skin Rashes in Children; and Immunization Schedule, Children.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to consider the diagnosis in a patient with a potentially pregnant and unimmunized family member
• For the obstetrician, failure to perform serologic screening for rubella.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Kelli N McCartan, MD, to the development and writing of this article.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  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.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

1. CDC. Elimination of rubella and congenital rubella syndrome--United States, 1969-2004. MMWR Morb Mortal Wkly Rep. Mar 25 2005;54(11):279-82. [Medline].
2. Elliman D, Bedford H. MMR: where are we now?. Arch Dis Child. Dec 2007;92(12):1055-7. [Medline].
3. CDC. CDC. Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report. Achievements in Public Health: Elimination of Rubella and Congenital Rubella Syndrome—United States, 1969-2004. JAMA. 2005;293:2084-6.
4. Fisher RG, Boyce TG. Prenatal infections. In: Moffet's Pediatric Infectious Disease: A Problem-Oriented Approach. Lippincott Williams & Wilkins; 2005:631-2.
5. Maldonado Y. Rubella. In: Behrman RE, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. Philadelphia, PA: WB Saunders; 2004:1032-4.
6. Mercurio MG, Elewski BE. Cutaneous manifestations of systemic viral, bacterial, and fungal infections and protozoal disease. In: Dermatologic Signs of Internal Disease. 2^nd ed. 1995:254.
7. Palacin PS, Castilla Y, Garzon P, Figueras C, Castellvi J, Espanol T. Congenital rubella syndrome, hyper-IgM syndrome and autoimmunity in an 18-year-old girl. J Paediatr Child Health. Oct 2007;43(10):716-8. [Medline].
8. Sanchez PJ. Viral infections of the fetus and neonate. In: Feigin RD, Cherry J, Demmler GJ, Sheldon S, eds. Textbook of Pediatric Infectious Diseases. Philadelphia, PA: Saunders; 2004:881-5.
9. Smith A, Yarwood J, Salisbury DM. Tracking mothers' attitudes to MMR immunisation 1996-2006. Vaccine. May 16 2007;25(20):3996-4002. [Medline].
10. Watstein SB, Jovanovic J. Statistical Handbook on Infectious Diseases. Westport, CT: Greenwood; 2003:5.

Article Last Updated: Dec 19, 2007