German Measles (Rubella)
AHMED SULTAN
Definition
• German measles is an acute, infectious, viral disease,
usually of older children and young adults, clinically
characterized by mild prodromal symptoms, typical rashes
and lymphadenopathy.
• It is mildest of all exanthematous (eruptive) diseases. It is
so mild that it causes much less inconvenience to the
patient than common cold.
• Even though it is such a mild disease, the importance lies
in the fact that it can cause damage to the growing fetus,
when a woman contracts the disease during pregnancy.
Thus rubella maims fetus for life.
• Disease is worldwide in distribution, occurring
sporadically, often in epidemics, once in 6 to 8
years.
Agent Factors
• It is a RNA virus belonging to togavirus group
readily inactivated by heat and chemical
agents.
• The rubella virus is known by its teratogenic
effects rather than by its composition.
• Reservoir: Humans are the only known
reservoirs and the source of infections is
usually a case.
• Large number of subclinical infections also act
as a source of infection.
• There is no known carrier state.
• Infants born with congenital rubella are also
infectious.
• Infective material: This is the respiratory and throat
secretions.
• Period of communicability: Rubella is less
communicable than Rubeola because of absence of
cough.
• However, it is infectious 1 week before and 1 week
after the appearance of rashes.
• Infectivity is greatest at the time of cutaneous rashes.
• Age and sex incidence: It is a disease of older children
and adolescents.
• Maximum incidence is in the age group of 5 to 10
years. However, people of all the age group and both
the sexes are susceptible to infection.
• Immunity: One attack confers life long immunity.
• Infants born to immune mothers are protected only
for about 6 months. Many acquire immunity as a
result of subclinical infection.
• However, about 40 percent of the population escape
infection and remain susceptible. This includes
women of childbearing age also.
• Mode of transmission: It is mainly by droplet
route. The disease is also transmitted trans-
placentally from the mother to the fetus.
• Incubation period: It is about 15 to 20 days.
• Pathology and pathogenesis: Having entered the
body through the respiratory route, the viruses
reach the cervical group of lymph nodes, where
they multiply, reach an optimum number and
enter circulation (viremia) and ultimately lodge in
the skin, resulting in the development of rashes.
• But when the virus enters the fetus via the
placenta, damages many organs because of
organogenesis of the fetus.
Clinical Features
1. Prodromal stage: Usually the symptoms are mild,
characterized by mild fever, coryza, sore-throat, dry cough
lasting for a day or two. This stage indicates the onset of
viremia.
2. Lymphadenopathy: In most of the cases, the
postauricular and posterior group of cervical lymph nodes
enlarge slightly one week before the appearance of
rashes and persist for about 10 to 15 days after the
disappearance of the rashes.
They are not tender among children but often tender
among adults.
• 3. Exanthematous stage: Fine maculopapular
rashes appear first on the face within 24 hours of
the onset of prodromal symptoms.
• They are small, pale, pinkish and discrete (not
confluent as in measles).
• They spread rapidly to trunk on second day and
extremities on 3rd day. By the time, they appear on
extremities, they will disappear over the face, thus
lasting for 3 days only.
• So it is also called as 3-day measles.
• Rash is an inconsistent feature. It does not
appear in about 25 percent of cases and
subclinical cases.
• If the rash is atypical, cervical lymph-
adenopathy is often a helpful diagnostic sign.
Complications
• Arthritis and arthralgia is a common
complication particularly among women.
• Encephalitis is very rare.
• Common dreadful complication is congenital
malformation of the fetus in a pregnant
mother.
Diagnosis
• The disease goes unrecognized, unless it is an epidemic.
• Definitive diagnosis is only by virus isolation from throat
swab. However, serological confirmation can be done by
hemagglutination inhibition test of a paired sample of sera,
the first sample drawn within 5 days of onset of illness and
second sample 2 weeks later.
• A four-fold rise in IgG antibody liter (HI) in the second
sample or detection of IgM antibody in the second sample
is diagnostic.
• Sensitive serological tests are ELISA and radioimmune
assay
Congenital Rubella (Rubella Syndrome)
• This refers to infants born with a number of
defects due to intrauterine infection with
rubella virus, occurring in the early part of its
fetal life, the primary infection being occurring
in the mother during early pregnancy.
• Since the fetus is in the stage of
organogenesis, the rubella infection inhibits
cell division, resulting in multiple structural
defects.
• Thus congenital rubella is a chronic infection
while acquired rubella is an acute infection.
• The fetus remains infected throughout the
period of gestation and for many months or
years after birth.
• The gestational age at which maternal
infection occurs is a major determinant for the
extent of fetal damage. In other words, the
earlier the infection during pregnancy, greater
will be the damage to the fetus.
• Thus, the first trimester of pregnancy is the
most disastrous time for the fetus, because it
is in the stage organogenesis.
STAGE OF GESTATION RISK OF DAMAGE TO THE
FETUS
4 to 8 weeks 80 percent
8 to 12 weeks 25 percent
12 to 16 weeks 10 percent
> 17 weeks 00 percent
• If the infection is serious, spontaneous
abortion and still-birth may occur.
• If the child is born alive, it will have developed
minimum multiple defects such as the classical
triad of patent ductus arteriosus, cataract and
deafness.
• Infection in the second trimester may cause
only deafness, but infection after 16 weeks,
suffers no major abnormalities.
• The damages of the heart, eyes and ears
together constitute ‘Rubella Syndrome’ or
‘Congenital Rubella’.
Prevention
• Prevention of rubella really means prevention
of congenital rubella, because acquired
rubella is of minor clinical significance, except
when it affects pregnant mothers.
• Prevention is by active and passive
immunization.
