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Despite the MMR vaccine, a case of “German Measles” can show up in your ED

The case occurred at the San Antonio Military Medical Center – South Campus (formerly known as Wilford Hall Medical Center) in San Antonio, Texas. At the time of presentation the emergency department was a busy Level II trauma center primarily serving active duty military personnel, military dependents and select civilian personnel.

An 8-year-old boy presented to the ED with several days of fever, malaise and a diffuse rash. The rash started on the face, then nearly resolved before spreading to the rest of the body. His history was otherwise unremarkable, and he denied ever having a similar rash. His immunizations were up to date. He denied any past medical history or chronic medication use. His parents had been giving him ibuprofen and acetaminophen for symptomatic relief.

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On physical examination he was well-appearing, afebrile, and had normal vital signs for his age. He had a diffuse, maculopapular, non-urticarial rash to his upper extremities including the palms, lower extremities, and trunk. The rash blanched, was nonfriable, and manifested no excoriations, crusting, or weeping. There was no cellulitis. The rest of his exam was normal. Viral titers were sent and returned positive for Rubella during his follow-up visit.

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Rubella Discussion

  • Incubation period of 10-14 days after inoculation via airborne droplet
  • Rash starts on the face, then starts to clear, spreading to the body in a centrifugal manner with resolution usually within 3 days, hence the nickname “three day measles”
  • Most commonly appears in children 5 to 15 years old
  • Well-documented history of being mistaken for drug-eruptions and exanthema subitum (roseola)
  • Viral testing rarely changes clinical management
  • 85% of pregnant women that are exposed with seroconversion during the first trimester will have a baby with Congenital Rubella Syndrome
  • Classic Congenital Rubella Syndrome (CRS)Triad:
  1. Sensorineural deafness
  2. Eye Abnormalities
  3. Congenital Heart Disease
  • Post-exposure prophylaxis should be considered in pregnant women
  • Serious complications for the patient are very rare, though mild symptoms, such as arthralgias may persist for several weeks
  • An estimated 2-5% of children vaccinated will be “non-responders”
  • 8-14% of confirmed Rubella infections were in previously vaccinated patients
  • Estimated incidence is 5 per 100,000,000


Conclusions

  • If suspected by clinical presentation, vaccination does not eliminate Rubella from the differential diagnosis
  • Infants can have devastating consequences of Rubella exposure in utero, therefore ensure patient is not exposed to pregnant women



Opinions of the authors do not reflect the official policy of the US Government, or the Departments of Defense, the Air Force or the Army.

 

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