Abstract
Rubella is an acute, contagious, exanthematous disease caused by Rubivirus. It is spread only by human beings, through respiration or transplacentally. It is essentially extinct in the United States after the introduction of the measles, mumps, and rubella (MMR) vaccines in 1969; about 20,000 were born with congenital disease in the mid-1960s. In the United States, acquired cases are typically contracted from foreign visitors or travel.
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Keywords
Overview
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Definition
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An acute, contagious, exanthematous disease caused by Rubrivirus
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Spread only by humans, via respiratory route or transplacentally
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Essentially extinct in the United States after the introduction of the measles, mumps, and rubella (MMR) vaccines in 1969; about 20,000 were born with congenital disease in mid-1960s
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In the United States, acquired cases are typically contracted from foreign visitors or travel
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Symptoms
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Redness
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Purulent discharge
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Photophobia
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Sudden vision loss
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Laterality
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Unilateral or bilateral
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Course
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Acute and self-limited
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Age of onset
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All age groups affected
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Gender/race
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No gender or racial predilection
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Systemic association
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Congenital rubella syndrome (CRS)
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Cardiac, hearing, and ocular defects
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Severity depends on time of maternal disease contraction: most severe during first trimester (miscarriage may result); defects unlikely after 20 weeks gestation
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Acquired rubella (German measles)
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Spread by respiratory route; common in spring and winter
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Incubation period of 2–3 weeks; hosts are contagious 1 week prior to rash onset and throughout active symptoms
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Exam: Ocular
Congenital Rubella
Ocular findings can be present at birth, shortly after birth, or later in life
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Salt-and-pepper retinopathy (inactive chorioretinitis, usually confined to RPE)
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Unilateral or bilateral
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Typically stable but may progress later in life
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Vision ranges from normal to 20/200
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Rarely complicated by CNV. May have focal necrosis of ciliary epithelium, pars plicata, or pars plana
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Nuclear cataract
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Significant AC inflammation after cataract extraction due to liberation of live virus from lens. Some cataracts have been known to resorb, leaving KP’s behind
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Glaucoma
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Corneal clouding and buphthalmos
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Microphthalmia
Acquired Rubella
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Conjunctivitis
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Most common ocular finding (70%)
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Epithelial keratitis
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Infrequent and resolves without sequelae within 1 week
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Retinitis
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Rare
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May present as multifocal exudative RD and RPE detachment
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No retinal hemorrhage
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Chronic rubella has been implicated as a cause of Fuchs’ heterochromic iridocyclitis (Chap. 11)
Exam: Systemic
Congenital Rubella
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Unilateral or bilateral deafness (>80%)
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Cardiac malformations: patent ductus arteriosus, peripheral pulmonary artery stenosis, and interventricular septal defects
Acquired Rubella
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Rubella exanthem
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Erythematous and maculopapular
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Spreads from face down to hands and feet over 24 hours
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Resolves by day 3 (thus second nickname “3-day measles”)
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Not always present
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Fever
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Variable
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After rash in children; before rash in adolescents and adults
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Postauricular and suboccipital lymphadenopathy
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Other complications: arthritis, encephalitis, thrombocytopenic purpura
Imaging
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FA
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Abnormal hyperfluorescence and hypofluorescence in salt-and-pepper retinopathy
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Early hyperfluorescence with late leakage in CNV
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Hyperfluorescence associated with area of retinitis without vascular leakage in acquired rubella
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ERG
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Normal in salt-and-pepper retinopathy
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Laboratory and Radiographic Testing
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Maternal serum rubella titers
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Viral culture and/or reverse-transcriptase PCR of amniotic fluid, nose, throat, urine, blood, or cerebrospinal fluid (CSF)
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Serum IgM titer is useful in children with anomalies from uneventful pregnancies
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Hearing test
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Echocardiogram
Differential Diagnosis
Congenital Anomalies
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TORCH infections
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Toxoplasmosis
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Other infections (syphilis, parvovirus, varicella zoster, Zika)
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Rubella
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Cytomegalovirus
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Herpes simplex
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Salt-and-pepper Retinopathy
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Congenital syphilis
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Congenital measles
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Leber’s congenital amaurosis
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Retinitis pigmentosa carrier
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Choroideremia carrier
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Albinism carrier
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Cystinosis
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Drug toxicity (e.g., phenothiazine)
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Kearns–Sayre syndrome
Salt-and-pepper Retinopathy and Hearing Loss
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Congenital syphilis
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Usher’s syndrome
Treatment
Congenital Rubella
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Mothers infected during first trimester should be counseled about possible birth defects
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Immune globulin within 72 hours of exposure during pregnancy
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Rubella vaccination is contraindicated during pregnancy
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CRS infants are contagious at birth and need isolation
Acquired Rubella
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Treatment is supportive, as there is no known antiviral therapy for rubella
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Topical NSAIDs and artificial tears to reduce conjunctival hyperemia
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Retinitis can benefit from corticosteroids
Referral/Co-management
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Audiology
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Cardiology
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Infectious Disease
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Small, K.W. (2021). Rubella. In: Foster, C.S., Anesi, S.D., Chang, P.Y. (eds) Uveitis. Springer, Cham. https://doi.org/10.1007/978-3-030-52974-1_38
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DOI: https://doi.org/10.1007/978-3-030-52974-1_38
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