Peer Reviewed

Photoclinic

A Case of Rubella

Volume 60 - Issue 12 - December 2020

AUTHORS:
Kimberly Duffy, MD1 • Sandeep A. Gandhi, MD1,2

AFFILIATIONS:
1Peconic Bay Medical Center, Northwell Health, Riverhead, New York
2New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York

CITATION:
Duffy K, Gandhi SA. A case of rubella. Consultant. 2020;60(12):28-30. doi:10.25270/con.2020.06.00013

Received February 25, 2020. Accepted May 29, 2020.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Sandeep A. Gandhi, MD, 200 Hawkins Ave #1362, Ronkonkoma, NY 11779 (sanganmd@gmail.com)

 

A 53-year-old man with a history of hypertension presented to our hospital with a 10-day history of rash and fever.

He had been clinically diagnosed with chickenpox 1 week earlier at an urgent care facility and had been treated with valacyclovir. The rash, which originally was described as vesicular, had dried up by the time of presentation. However, the man still reported having fever, generalized joint pain, and a new swelling of the bilateral upper and lower extremities. Additionally, he reported having shortness of breath while climbing steps, a nonproductive cough, and generalized weakness. He denied having chest pain, hemoptysis, abdominal pain, nausea, vomiting, sick contacts, travel history, or a zoonotic exposure.

On physical examination, he had a temperature of 36.7 °C, blood pressure of 150/95 mm Hg, heart rate of 88 beats/min, respiratory rate of 18 breaths/min, and oxygen saturation of 100%. Examination of the skin showed a diffuse, blanching, hyperpigmented, nonpruritic, macular, patchy rash over the whole body (Figures 1 and 2).

Fig 1
Figure 1. A diffuse, blanching, hyperpigmented, nonpruritic, macular, patchy rash on the patient’s back.

Fig 2
Figure 2. A diffuse, blanching, hyperpigmented, nonpruritic, macular, patchy rash on the patient’s buttocks.

Bilateral upper- and lower-extremity evaluation revealed 2+ nonpitting edema. The patient was admitted to the medical floor for further evaluation of continued symptoms. He was started on intravenous acyclovir, meropenem, and vancomycin for possible superimposed bacterial infection.

Laboratory test results at admission were as follows: white blood cell count, 9,600/µL; hemoglobin, 11.9 g/dL; hematocrit, 33.7%; platelet count, 473 × 103/µL; and ferritin, 920 ng/mL. Results of a comprehensive metabolic panel were within normal limits. The erythrocyte sedimentation rate was 70 mm/h, and the C-reactive protein level was 18.97 mg/dL. Blood, urine, and throat cultures did not reveal any growth. Test results for influenza A and B, respiratory syncytial virus, and Lyme disease were negative. Varicella IgG antibodies were positive, but polymerase chain reaction assay results were negative. Rubella IgM antibodies were elevated, and rubella IgG antibodies were positive.

Electrocardiography showed normal sinus rhythm at 91 beats/min, and chest radiography findings were normal.

His symptoms improved after 3 days of hospitalization (Figure 3), and he was discharged on 100 mg of doxycycline every 12 hours for 1 week.

Fig 3
Figure 3. The patient’s rash had improved after 3 days of hospitalization.

Discussion. Rubella, also referred to as German measles, was declared eliminated from the United States in 2004, but rare cases (fewer than 10 per year) are still seen here.1

Rubella typically presents with a maculopapular erythematous rash, starting on the face and typically spreading to the rest of the body within 24 hours. It also can present with viral symptoms such as fever, arthralgias, fatigue, and occasionally lymphadenopathy. It is a contagious virus, spread through nasopharyngeal secretions until 1 week after the development of the rash.2 In order to prevent the spread of this potentially deadly virus, patients with similar symptoms must be placed on droplet precautions prior to receiving test results.

The Centers for Disease Control and Prevention recommends throat culture as the best source of testing, but nasal or urine swabs may also be used.1 Testing for rubella virus consists of serology testing for IgM and IgG antibodies, most specific after 5 days of the onset of symptoms.

While this virus has become rare in the United States as a result of vaccinations, it remains important to recognize the symptoms of presentation to prevent complications and the spread of infection. Its presentation can be confused with other more common infections such as varicella. Arthritis and arthralgias tend to be the most common complication following infection, but more serious complications such as encephalitis can occur.2

It is particularly important to prevent transmission to pregnant women. If infection with the rubella virus occurs prior to or within the first 8 to 10 weeks after conception, there is a 90% chance of fetal birth defects occurring,2-5 and fetal demise is common. According to the World Health Organization, a minimum vaccination rate of 80% of the population is necessary to prevent these complications and the spread of this virus.6 The percentage of the global population receiving the rubella vaccine has continued to increase, and by 2018, approximately 87% of countries including the United States had begun to incorporate this vaccine into medical care.4

REFERENCES:

  1. Centers for Disease Control and Prevention. Rubella (German measles, three-day measles) for health care professionals. Reviewed September 15, 2017. Accessed June 2, 2020. https://www.cdc.gov/rubella/hcp.html
  2. White SJ, Boldt KL, Holditch SJ, Poland GA, Jacobson RM. Measles, mumps, and rubella. Clin Obstet Gynecol. 2012;55(2):550‐559. doi:10.1097/GRF.0b013e31824df256
  3. Lambert N, Strebel P, Orenstein W, Icenogle J, Poland GA. Rubella. Lancet. 2015;385(9984):2297‐2307. doi:10.1016/S0140-6736(14)60539-0
  4. Grant GB, Desai S, Dumolard L, Kretsinger K, Reef SE. Progress toward rubella and congenital rubella syndrome control and elimination—worldwide, 2000–2018. MMWR Morb Mortal Wkly Rep. 2019;68(39):855‐859. doi:10.15585/mmwr.mm6839a5
  5. Dimech W, Panagiotopoulos L, Marler J, Laven N, Leeson S, Dax EM. Evaluation of three immunoassays used for detection of anti-rubella virus immunoglobulin M antibodies. Clin Diagn Lab Immunol. 2005;12(9):1104‐1108. doi:10.1128/CDLI.12.9.1104-1108.2005
  6. World Health Organization. Rubella vaccines: WHO position paper. Wkly Epidemiol Rec. 2011;86(29):301‐316. Accessed June 2, 2020. https://www.who.int/wer/2011/wer8629.pdf