DIAGNOSIS

AND
Louis

Department

of

Z.

Cooper,

Pediatrics,

New

INTRODUCTORY

appears

section.

Each

regard
for

States

to 20,000

of

one
history.

and

been

infants

acquired

well
port

documented
in 1941.

may

by

have

Buescher,

significant

contribution
with

been

at

atric

joint

Research

have

OF

added

summarized
Aided

with

Ncva2

by

related

our

by

ADDRESS:

Public

York

Service
the

from

(L.Z.C.

or S.K.)

nancy

and

recovered

for

by

of
and

infection

persists
is

at

from

fetal

months

after

acquired

and

maternal

many

Infants

tion

may

other

with

to

advancing

Grant

the

the
inbe

first

month

AI-04335

from

the

3 to
National

shed

rubella
virus

for

by

infecmonths

our
group
decreases

Preliminary

data

are

cultures
during

in 31% of 68 infants,

age;
old,

in 7% of 84 infants,
and
in none
of 20

15 years
Institute

infec-

cultured
from
cerebrospinal

tissues.

of life;

5 to 7 months
of
10 to 13 months

Foundation-March

weeks

Figure
1. Positive
in 63% of 119 infants

in

detected

were

cpidem-

550 First

age.

summarized

Virus
has
obtained

rubella

congenital

continue

in

preg-

performed

tion. At birth,
virus
has been
pharyngeal
secretions,
urine,
2.

by

Group).

birth.
tissues

abortions

con-

studies

throughout

present

therapeutic

with

rubella
may

as above,

from

virus

cor-

with

Research

been

investigators

National

children

Rubella

in-

fluid,

isolation

virus

and

accumulated

generally

children,

Health

infants

(data

1. Rubella

and

CHILDREN

rubella

after
birth.
Recent
studies
indicate
that
virus-shedding

knowledge

a grant

in

AND

3-IS yeas

University

utero

ADVANCES

aspects,

age

.0%

l0-l3months

INFANTS

of

rubella

New

Childrens

of congenital
recent
advances

with

genital

a symposium

many

OF

Incidence

by
This

needed

and

1.

FIG

reour

many

31%

5#{149}7
mo,,hs
ASE

been

and

01 onfh

as follows:

and

in

suggestions

#{149}N618.

infec-

Artenstcin.3

RECENT

to

aspects
These

welcome

\2/68

in 1965.

clinical

iological
fection.

Reason
practice

30

the American
PediSociety
for Pediatric

the

observations

pathogenesis,

I)iseases

1964
of

SUMMARY

will

current

40

history
of rubella
were
the subject
of

in Philadelphia

New

Editor

pediatrics

and

50

of congeniIn that
year
cultivated
in

International
in

and

present

N.Y.

75/11963%

20

has

techniques

meeting

Society

of

Experience

to

York,

60

un-

born

provided

the

Paris

problem

the

10,000

rubella

and

and
the

at

in

New

70

in-

is
that

of

of the natural
These
studies

seminar

RUBELLA

M.D.

Medicine,

common

The

most

was

pregnancy

Weller

Parkman,

Center

the

since
Greggs
original
The
turning
point
in

culture

the study
infection.

both.

pregnant
precise
toll

estimated

in early

vestigators

or

of

intended

United

It

knowledge
of the pathogenesis
tal rubella
occurred
in 1962.
rubella
virus
was successfully
tissue

is

disability

congenital
malformations.
The
tcratogenic
effect
tion

some

preceding

papers

Krugman,

School

of

article

the

many
susceptible
be infected.
The

has

Saul

discussion

therapy

in

was

death

It

or

and

University

last
short

rubella

medical

neonatal

known.

these

M.D.,
York

CONGENITAL

topics.

1964

that
would

the

diagnosis

of

in

evitable
women

as

of

desirable

in

extensive

in

to

epidemic

lIE

NOTE:

regularly

MANAGEMENT:

old.
of

Allergy

and

Infectious

of Dimes.

Avenue,

New

York,

PEDIATRICS,

N.Y.

10016.
VOL.

37,

No.

2,

FEBRUARY

1966

335

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 28, 2015

336

CONGENITAL
TABLE
MANIFESTATIONS

OF

History

DIAGNOSIS

H DBELLA

CONGENITAL

Common

Uncommon

of maternal

Low birth

rubella

Rare

Dermatoglyphie

abnor-

Glaucoma

Retinopathy

Cloudy

Deafness

cornea

Myocardial

Congenital
heart
Thrombocytopenic

disease

Hemolytic

adenopathy

manifestations

Splenomegaly

anemia

Hypoplastie

lesions

(metaphyseal

anemia

Cerebrospinal

rarefaction)

fluid

pleo-

cytosis

anterior

Psychomotor

Spastic

fontanelle

with
congenital
neutralizing

comparable

to

those

rubella
antibody

have
titers

served
ative

of

observed

in

their

end

of the

may
be
neutralizing
many

year,
67

antibody

IgG

(75)

rubella

neutralizing

clinical

syndrome
manifestations

have

rubella-associated

epidemic

of 1964.

of

the

expanded
were
not

The

defects

prior

various

common

manifestations
listed
in Table

5. Virus
isolation
body
studies
have

and
revealed

rubella

infection

appear
months

to
of

infants

with

available

be
life.

as yet.

can

to
of
1.

occur

It is well

con-

neutralizing
antithat congenital
in

infants

who

normal
during
the
An adequate
follow-up
subclinical

the

infection
known,

that the recognition

of certain
as deafness,
may be delayed.
6. Infants
with
congenital

of
is

not

however,

defects,
rubella

5 to

during

early

MANAGEMENT

The

unique
with
the

care.
sent

OF

available

at

isola-

obtained

on

persistence

of

in the

serum
of

age;

neutralfraction

INFANTS

WITH

presented

by

rubella
have
provide
guidelines
concerned

present

in-

highfor

with

recommendations
based
on

the

indic-

RUBELLA

arc

following
opinion

a
ob-

urine,

6 months

problems
congenital
need
to
who

The
our

their

repreinformation

time.

Isolation

for

The primary
aim
these
contagious

the

spread

women

early

tissue
and

infancy.

serum

physicians

and

are
(1

antibody

over

of

findings,

of

fants
lighted

rubella

support

of rubella
1gM
(195)

of
for

to include
recognized

uncommon
clinical
genital
rubella
are

infant

the

1.

pharynx,

or any

presence

CONGENITAL

Detectable
levels
appear
to persist

aspects
been
which

the

from

or

of

of conclinical

and (3) the identification

izing
antibody
in the

antibody

years.8

4. The

as

first

fluid
(2)

mothers.
The predominant
antibody
appears
to be 1gM (19S ) up to 7 months
of age; by
the

the
following

virus

biopsy;

one

of a diagnosis
or without

The

rubella

preg-

of

singly
or in combination,
a congenital
infection:

of

an

should
circumpossible

in early

presence

requires

laboratory.

of
3. Infants
serum
rubella

the

confirmation
rubella
with

cerebrospinal

retardation

to rubella
(2)

virus

tion

quadripareses

RUBELLA

the various
manifestations
syndrome,
as listed
in Table

damage

Generalized

purpura

Hepatomegaly

or exposure
and/or

Final
genital

Hepatitis

rubella
of

CONGENITAL

of congenital
rubella
under
the following
maternal
history
of

nancy,
more
rubella

mality

Microphthalmia

Large

or

OF

A diagnosis
be suspected
stances
: (1

Jaundice

weight

Cataracts

Bone

RUBELLA

in

Recent
contact

of
the

of isolation
procedures
infants
is to prevent

infection
early

studies
have
is generally

mission

of

rubella.

Rubella

virus

destroyed.

The

have

contracting
is probably

rubella
via
inconsequential.

potentially

susceptible

infants.

congenital

avoid

ISOLATION

physical
IN

rubella

THE

pregnancy.

that intimate
for the trans-

labile

should
fants.

easily

susceptible

of

indicated
required

such

been
shown
to be contagious.
We are aware
of 22 instances
of rubella
in nurses,
doctors,
medical
students,
and family
members
who
were
intimately
exposed
to virus-shedding

and

to

stages

the

is very
risk

pregnant
contact

with

women
these

: Infants

HOSPITAL

should

of

air-borne
route
Consequently,

be

admitted

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 28, 2015

inwith
to a

ARTICLES
separate
room.
room
may
be
unit.

In most
designated
assigned

Personnel

be

selected

on

status
and
laboratory

basis

to screen
of
serum

antibody.

the

assigned

to

survey
dcmic

conducted
indicated

women

IN

are

family.
who

physical
period

THE

for

be

contact
with
of contagion.

If

of

throat

been

swab

evidence

of

are

not

1 may

be

available,

Management
Special

for

attention

may

infants;
on the other
in a small
number
If laboratory
facilican

only

be

and

abdomen

of

daily,

any

controlled

the

Although

rubella.
volved

devoted

other

to
during

study,

latter
we

is

black

pig-

and

loca-

we

do

size

by
there

the end
may
be

and

spleno-

weeks.
Hepatomegaly

minimal
at birth;
progresoccasionally
occurs
during

period.
Evaluation

frequency

of pediatric

must
of the
Since
by

any

this

follow-up

be based
infant
organ

on
with
system

infection,

specialists

is

arc

sultant
can
opportunity

be most
effective
to follow
the

disease

As

from

the

hearing

be

does

previously,

given
loss

ab-

The

con-

Therapy

fants
should
be evaluated.
evaluation
may reasonably

of

precau-

congenital

suspected,

has an
of the

not require
varpediatric
practice.
isolation

audiometric
is

from

if he
course

beginning.

tions may be indicated.

All
children
with
should

be in-

when

suspected.

abnormalities
from
established

indicated

may

warranted

first

cx-

the clinical
congenital

consultation

normalitics

specific
iation
a

lesions
are

of several

neonatal

The

during
the
first
24 hours
after
may
be extensive
and persistent
for
In others,
the
petcchiac
may
be
and transient.
If the newborn
infant
seen.

in

usually
detected
week.
However,

ABDOMEN:

spec-

purpura

be

delay

an infant
in Figure

of severe
congenital
the purpura,
which

examined

are
first

aminations
condition

Period

should

variable

Auscultation
for the presence
of
murmur
should
be repeated
daily.

Follow-up

manifestation
In some
cases,

not

cxthe

1,

examination.
Thrombocytopcnic

not

indicate

eye.

the

have

disappear

Neonatal

heart,

may

( patchy

retinopathy
quite

megaly
may
be
sive enlargement

Figure

daily

appears
birth,
weeks.
scanty

rubella

a cardiac

as a guide.
in the

finding

Ophthalmoscopic

is required
for detection
of
cataracts
as well as for visualization

HEART:

the

eyes,

common
rubella.

aware

avoid

skin,
SKIN:

is

in

one

important

fants

the probability
that
The data presented
used

of

clouding,
if present,
may
easily
overlooked.
If it per-

visi-

immediate

cultures

virus-shedding

been
throm-

tion).
The
small
rubella
cataract
is a central lcnticular
opacity
easily
visualized
with
the
+ 8 lens held
6 to 8 in. from
the in-

available

urine

of the

pre-

during

indicated

severity

glaucoma.

mentation

rubella
virus,
infants
contagious
until nega-

by one month
in some
hand,
it may be present
of infants
at one year.
ulate
about
is contagious.

this

amination
smaller

As

the

special

female

arc

of

Corneal
and

be transient

Murmurs
of the

and

obtained.

spite

were

infant

facilities

identification
of
should
be considered

may

Isolation

laboratory

of the thrombocytopenic
hemorrhage
has

infantile

epi85%

should

the

the course
Spontaneous

sists,

unit.

the

pregnant

altered
purpura.
in

has

clinics
No

susceptible

of corticosteroids

EYES:

for

persons

rubella

HOME:

necessary

may

Duration

the

the

prenatal

Potentially

tors

the

immune

administration

hocytopenia.

to rubella.10

cautions

ties

If virus
it would

members
neutralizing

believe

rare

immune

prior
to the
1964
that
approximately

attending

ISOLATION

tive

staff
rubella

only

be

their

potential.
available,

Ideally,

should

immune

of

child-bearing
facilities
are

be wise
presence

of

the

hospitals
a private
as the isolation
to this unit should

337

rubella

testing.
even

When
small

However,
be deferred

inthis
un-

not

til age 4 to 5 years

in children
with
apparently
normal
hearing.
Rubella-associated

not

deafness

is

usually

not

complete.

There-

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 28, 2015

338

CONGENITAL

fore,
be

it is quite

desirable

prescribed

training

should

There
is
from surgery
cataract.

be

found

of

case of bilateral
the age of six
any

advantage.

1.

optimal
in

the

surgery

by

therapy

the

is available

rubella
carrier.
a self-limiting

possible
benefit
ment
program

Ophthal.

Soc.

Weller,

for

Parkman,

P.

army

recruits.

on the

natural

of congenital
rubella
are
ress
in various
pediatric
United
many
many

States.
infants
of the

today.

Long
with this
problems

When

comes
available,
diagnosis
and
The

final

solution

currently
centers

term

a more
treatment
of the

in progin the
of

should
clarify
to cope with

information
definitive
may be
rubella

8.

course

observation

disease
difficult

additional

and

be-

problem

is

pa-

Proc.

Soc.

1962.
E.

L.,

rubella

Proc.

Soc.

Exp.

and

Arten-

virus

from

Biol.

Med.,

the

epidemiology

and

and

rubella.

prevention

Arch.

Ges.

Virus-

1965.

Amer.

J. Dis.

Child.,

110:

C.

A.,

Jr. : Studies

rubella

110:455,

L. :

antibody

in

J.

Amer.

Dis.

1955.

J. A., Artenstein,
E.

on

infections.

L.,

Congenital
110:464,

M. S., Olson,

Luhrs,

C.

E.,

rubella.

and

L. C.,

Milstead,

J.

Amer.

Dis.

1965.

Plotkin,
S. A., Dudgeon,
J. A., and Ramsay,
A. M. : Laboratory
studies
on
rubella
and
rubella
syndrome.
Brit.
Med.
J., 2: 1296,
1963.

9. Green,
R.
Krugman,
the

report
on
indicated.

illness.

of

Symposium.

Child.,

history

in

from

1965.

Child.,
7. Bellanti,
K.

agents

Buescher,

16:377,

6. Afford,

SUMMARY

A. : Propagation

S. : Recovery

measles

congenital

hazard.

F.

cytopathic

1962.

on

345,

Trans.

1941.

111:215,

D.,

M.

following

mother.

3:35,

Neva,
of

Nied.,

stein,

5. Rubella

the

rubella-like

Biol.

forsch.,

apthe

and

with

Exp.
3.

H.,

Buescher,

Studies

of a safe

cataract

in
Aust.,

culture

4. Seminar

treat-

Since
this
condition,

T.

111:225,

course

from
any
proposed
treatmust
be carefully
measured

its potential

development

M. : Congenital
measles

tients

in the mancan prevent

in

N.

German

tissue

Operation
before
not appear
to

early

the

vaccine.

Gregg,

of

of the
to be

against

the

experienced
glaucoma

upon

effective

REFERENCES

opinions

In contrast,

if performed

of this disease.
No specific
ment
pears

does

and

infancy.

technique

cataracts.
months

dependent

be
gained
of unilateral

differing

surgical

an ophthalmologist
agement
of infantile
blindness

to

concerning

type

aids

Auditory

during

little
correction

authorities
and

offer

started

have

hearing

indicated.

probably
for the

We

among
age

that

when

RUBELLA

10.

natural

H., Balsamo,
M. R., Giles,
J. P.,
S., and Mirick,
G. S. : Studies
of
history

and

prevention

of rubella.

Amer.
J. Dis. Child.,
110:348,
1965.
Sever, J. L., Schiff,
G. M., and Huebner,
R. J.:
Frequency
of rubella
antibody
among
pregnant women
and other
animal
populations.
Obstet.
Gynec.,
23:153,
1964.

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DIAGNOSIS AND MANAGEMENT: CONGENITAL RUBELLA

Louis Z. Cooper and Saul Krugman
Pediatrics 1966;37;335
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1966 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 28, 2015

DIAGNOSIS AND MANAGEMENT: CONGENITAL RUBELLA

Louis Z. Cooper and Saul Krugman
Pediatrics 1966;37;335

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/37/2/335

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1966 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 28, 2015