Measles Disease

BASICS

DESCRIPTION
An endemic and epidemic viral exanthematous infection of children and adults, worldwide in distribution. Many infections are subclinical, but this virus can potentially cause fetal infection with resultant birth defects.
  • System(s) affected: Skin/Exocrine, Hemic/Lymphatic/Immunologic, Pulmonary, Nervous
  • Genetics: Children with congenital rubella syndrome and children with insulin dependent diabetes mellitus share a high frequency of HLA-DR3 histocompatibility antigen and a high prevalence of islet cell antibodies
  • Incidence/Prevalence in USA:
    • Before rubella vaccine was introduced in 1969, epidemics occurred at 6-9 year intervals. Sporadic outbreaks continue to occur in hospitals, colleges, prisons, prenatal clinics, and isolated religious communities
    • In 1999 the incidence of postnatal rubella was 0.09 cases per 100,000 population. Presently, the source of rubella outbreaks is from infected persons from countries where rubella is not included in routine immunization or just recently introduced schedules or administered in mass campaigns
  • Predominant age: Children 5-9 years of age
  • Predominant sex: Male = Female
SIGNS AND SYMPTOMS
  • Postnatal rubella
    • Adenopathy - posterior auricular, posterior cervical, suboccipital
    • Low-grade fever
    • Exanthem - descending, maculopapular, may desquamate
    • Enanthem - soft palate petechiae (Forschheimer's sign)
    • Conjunctivitis
    • Splenomegaly, rarely
    • Coryza
    • Malaise
    • Headache
    • Polyarthralgia/polyarthritis, especially in young women
    • Asymptomatic (25%-50%)
  • Congenital rubella: (T = Transient, P = Permanent, D = Developmental)
    • Cataracts (P)
    • Microphthalmia (P)
    • Chorioretinitis (P)
    • Patent ductus arteriosus (P)
    • Pulmonic stenosis (P,D)
    • Atrial and ventricular septal defects (P)
    • Sensorineural deafness (P,D)
    • Microcephaly (P)
    • Meningoencephalitis (T)
    • Mental retardation (P,D)
    • Low birth weight (T)
    • Purpuric ("blueberry muffin") skin lesions (T)
    • Radiolucent bone disease (T)
    • Hepatosplenomegaly (T)
    • Large anterior fontanelle (T)
    • Language and behavior disorders (P,D)
    • Cryptorchidism (P)
    • Inguinal hernia (P)
CAUSES
Rubella virus is a single-stranded RNA virus in the togavirus family. Traveling via airborne droplets of nasopharyngeal secretions, the virus replicates in the nasopharynx and regional lymph nodes during a 16-18 day incubation period. After invading the bloodstream, it may spread to skin and other distal organs or, transplacentally, to the developing fetus. Fetal viremia may then produce disseminated fetal infection. Organogenesis occurs 2 to 6 weeks postconceptional, so that infection is a maximum hazard (40-80% risk) to heart and eyes at that time. During the second trimester, the fetus develops increasing immunologic competence, making it less susceptible (10% risk) to the effects of intrauterine infection.
RISK FACTORS
  • Inadequate immunization
  • Immunodeficiency states
  • Immunosuppressive therapy
  • Pregnancy
  • Crowded living conditions
  • School, day care
  • Late winter, spring seasons
  • International travel aboard commercial airplanes, cruise ships

DIAGNOSIS

LABORATORY
  • Postnatal rubella
    • Mild leukopenia with relative lymphocytosis
    • Fourfold rise in serum levels of antibody to rubella virus
    • Pharynx, nose, and blood culture positivity to rubella virus
  • Congenital rubella
    • Presence of rubella-specific IgM antibody in serum up to one year of age, at which time, IgG becomes the dominant antibody
    • Isolation of rubella virus from pharynx, blood, urine, cerebrospinal fluid

Drugs that may alter lab results: N/A
Disorders that may alter lab results: After re-exposure to rubella, a person with a low level of antibody from past infection or vaccination may experience an acute rise in antibody. This is not associated with a high incidence of contagion to others nor of fetal risk.

PATHOLOGICAL FINDINGS
  • Inhibition of cellular growth after infection
  • Fetal vasculitis
  • Placental angiopathy
  • Tissue necrosis
SPECIAL TESTS
Cell-mediated immune responses (CMI) are impaired selectively in children with congenital rubella
IMAGING
N/A
DIAGNOSTIC PROCEDURES

Congenital rubella has been diagnosed by placental biopsy at 12 weeks

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient usually

GENERAL MEASURES
  • Postnatal rubella - mild and self-limited. Treat for symptomatic relief
  • Congenital rubella - supportive, unless neurologic or hemorrhagic complications develop
SURGICAL MEASURES

N/A

ACTIVITY
  • For postnatal rubella - contact isolation for 7 days after onset of rash, bedrest is not necessary
  • Contact isolation of congenitally infected infants for one year, unless nasopharyngeal and urine cultures after 3 months of age are negative for rubella virus
DIET

No special diet

PATIENT EDUCATION

Make every effort to avoid exposing infected patient to pregnant women

FOLLOW UP

PREVENTION/AVOIDANCE
  • Rubella vaccine
    • A 2-dose schedule in combination with measles and mumps (MMR) is recommended for those born after 1956. The first dose is recommended at age 12-15 months; the second dose is recommended either at 4-6 years of age or at 11-12 years of age. Children with HIV should receive MMR vaccine at 12 months of age if no contraindications exist
    • Recommended for susceptible individuals in the following groups: Prepubertal boys and girls, premarital or postpartum women, college students, day care personnel, health care workers, military personnel
    • It is contraindicated in: Pregnancy, immunodeficiency or immunocompromised state (except HIV), receipt within the last 3 months of immunoglobulin (Ig) or blood, severe febrile illness, or hypersensitivity to vaccine components
    • Persons who receive rubella vaccine do not transmit rubella to others, although the virus can be isolated from the pharynx
    • During outbreaks of rubella, serologic screening before vaccination is not recommended, because rapid vaccination is necessary to stop the spread of the disease
POSSIBLE COMPLICATIONS
  • Postnatal rubella
    • Postinfectious encephalitis (1/5,000 cases)
    • Thrombocytopenic purpura (1/3,000 cases)
    • Testicular pain
    • Mild hepatitis
  • Congenital rubella
    • Spontaneous abortion
    • Stillbirth
    • Premature delivery
    • Progressive rubella panencephalitis
    • Endocrine disturbances (diabetes, thyrotoxicosis, hypothyroidism)
  • Rubella vaccine
    • Lymphadenopathy
    • Fever
    • Rash
    • Arthritis/arthralgia (older girls, women)
    • Polyneuropathy
EXPECTED COURSE AND PROGNOSIS
  • Postnatal rubella
    • Fever, 1-2 days
    • Rash, 3 days
    • Coryza, 5 days
    • Lymphadenopathy, 1 week
    • Arthralgia (when present), 2 weeks
    • Complete and full recovery without sequelae is the rule
  • Congenital rubella
    • Varied and unpredictable spectrum of consequences, ranging from stillbirth to completely normal infancy and childhood
    • Disease characterized by chronic infection; infants may remain contagious for months after birth
    • Detectable levels of hemagglutination-inhibiting antibody (IgG) persist for years, then may decline. By age 5, 20% have no detectable antibody
    • Overall mortality 10%; greatest during first 6 months
    • 70% of those with encephalitis develop residual neuromotor defects, including an autistic syndrome
    • Prognosis is excellent when only minor defects are present

MISCELLANEOUS

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric:

  • Postnatal rubella is a milder disease in children than it is in adults
  • Adolescents and young adults currently account for about 60% of all new cases

Geriatric: N/A
Others: N/A

PREGNANCY
  • Women vaccinated against rubella are advised not to become pregnant for at least 3 months. The vaccine-type virus can cross the placenta. However, no case of congenital rubella has occurred after inadvertent vaccination
  • If a pregnant woman is exposed to rubella (native disease, not vaccine associated), obtain an antibody titer. Presence of antibody implies immunity and no risk. If antibody is not detectable, obtain a second titer in 3 weeks. If antibody is present in the second specimen, infection has occurred. If antibody is again negative, obtain a third titer in 3 more weeks (6 weeks after exposure). At this time, a negative test means that infection has not occurred; a positive test means that infection did occur, and the fetus is at risk for congenital rubella
  • Human immunoglobulin (gamma globulin) in prophylaxis of rubella during pregnancy does not prevent rubella or the congenital rubella syndrome in a predictable or reliable fashion
  • A reliable PCR-based method of detecting viral RNA may allow much more rapid prenatal diagnosis of rubella virus infection. Routine use is not yet available
OTHER NOTES

Rubella vaccine is currently the only vaccine designed for the purpose of protecting someone other than the vaccine recipient

ABBREVIATIONS

N/A

Clinical Investigations
  • Cardiology
  • Dermatology
  • General Destistry
  • Cardiology
  • Dermatology

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