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Snapshot
  • A 3-year-old girl is brought to the pediatrician’s office for a rash that began on the face and spread to the rest of her body. The rash is sometimes itchy. The girl also has a low-grade fever. She had just moved from South America to the US and had not received her childhood vaccinations. On physical exam, she has postauricular lymphadenopathy, a pink non-confluent maculopapular rash, and petechiae on her soft palate.
Introduction
  • Classification
    • rubella virus
      • an enveloped, single-stranded, positive-sense RNA virus
      • icosahedral capsid
      • a togavirus
      • causes rubella (German 3-day measles)
      • transmission via respiratory secretions
  • Epidemiology
    • incidence
      • decreased in the US due to vaccination
      • endemic in other parts of the world
    • demographics
      • any age can be affected
    • risk factors
      • lack of vaccination
      • travel to or from endemic areas
  • Pathogenesis
    • the virus replicates in the upper respiratory tract and lymph nodes
    • it then disseminates throughout the body
    • can spread through the placenta to cause vertical transmission
      • may result in miscarriage or congenital rubella syndrome
  • Associated conditions
    • congenital rubella syndrome 
      • blueberry muffin appearance
        • dermal extramedullary hematopoiesis
      • cataracts
      • deafness
      • congenital heart disease (pulmonary artery stenosis or patent ductus arteriosus)
  • Prevention
    • measles, mumps, and rubella (MMR) vaccine
      • given over 2 doses
  • Prognosis
    • infection may be asymptomatic but still contagious
Presentation
  • Symptoms 
    • low-grade fever
    • polyarthritis and polyarthralgia
      • more common in adult females
      • fingers, wrists, and knees are most commonly involved
  • Physical exam
    • lymphadenopathy before the rash
      • postauricular lymphadenopathy is classic
      • may also have posterior cervical and suboccipital lymphadenopathy
    • fine, pink, non-confluent maculopapular rash
      • starts on face and spreads to trunk and extremities
      • may be itchy
      • desquamates
      • rash resolves in 3 days
    • petechial rash on soft palate (Forschheimer spots)
    • orchitis
Studies
  • Labs
    • detection of rubella-specific immunoglobulin M or G
    • detection of virus on reverse transcriptase-polymerase chain reaction
  • Making the diagnosis
    • based on clinical presentation and confirmed with laboratory studies
Differential
  • Parvovirus B19 infection
    • distinguishing factors
      • slapped cheek rash
      • maculopapular rash on trunk and limbs that does not spread from head/neck downward
  • Measles
    • distinguishing factors
      • confluent maculopapular rash
      • coryza and Koplik spots
Treatment
  • Management approach
    • mainstay of treatment is supportive care and prevention with vaccines
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • anti-pyretics
        • analgesics
        • hydration
Complications
  • Vertical transmission to fetus
    • congenital rubella syndrome
  • Thrombocytopenic purpura
  • Guillain-Barré syndrome
 

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(M1.MC.15.75) A 2-week-old boy is brought to a pediatrician's office for evaluation. The boy was born at 32 weeks. The boy's mother immigrated to the United States from Eastern Europe several years ago. His mother is concerned that he does not appear to awaken to the sound of loud noises. She also notes that his eyes appear "cloudy" (Figure A). He has two older siblings, neither of whom is affected by similar problems. On physical exam, you hear a continuous murmur with machine-like consistency over the precordium. Which of the following is the most likely explanation for this child's problems? Tested Concept

QID: 106711
FIGURES:
1

Toxoplasma gondii

9%

(15/166)

2

Cytomegalovirus

11%

(18/166)

3

Syphilis

8%

(13/166)

4

HIV

1%

(2/166)

5

Rubella

65%

(108/166)

M 2 D

Select Answer to see Preferred Response

(M1.MC.13.11) A 35-year-old woman from San Francisco has been refusing to vaccinate her children due to the claims that vaccinations may cause autism in children. Her 10-year-old male child began developing a low-grade fever with a rash that started on his face; as the rash began to spread to his limbs, it slowly disappeared from his face. When the child was taken to a clinic, the physician noticed swollen lymph nodes behind the ears of the child. Which of the following are characteristics of the virus causing these symptoms? Tested Concept

QID: 101470
FIGURES:
1

Enveloped, DS linear DNA

11%

(6/55)

2

Nonenveloped, SS linear DNA

18%

(10/55)

3

Enveloped, SS + nonsegmented RNA

42%

(23/55)

4

Enveloped, SS - nonsegmented RNA

24%

(13/55)

5

Nonenveloped, DS segmented RNA

4%

(2/55)

M 2 E

Select Answer to see Preferred Response

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