• Rubella Symptoms in Children

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    Rubella is an infectious disease of viral origin, a fairly frequent viral infectious disease in children, manifested by small-stalk rash, minor inflammation of the upper respiratory tract, enlarged lymph nodes in acquired form or developmental malformations with congenital infection. After the incubation period, which lasts without symptoms and lasts from five to twelve days, suddenly a high temperature appears. Fever can last three to five days. At this time the child can become irritable and, in some cases, experience convulsions caused by fever. On the fourth or fifth day of illness, the temperature drops sharply, and a rash appears on the body.

    A rash consisting of small, red, flat spots, each about two millimeters in diameter, can quickly spread to the neck and face, as well as to the hands and feet. The rash often falls off after one or two days, and in some cases can persist for only a few hours. By the time the rash appears, the baby usually feels better, it has a normal temperature and is no longer infectious. How to use folk remedies for this disease look here.

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    Etiology. causative agent of rubella is a virus belonging to togaviruses( family Togaviridae, family Rubivirus).Vyrions are spherical particles with a diameter of 50-70 nm, contain a nucleocapsid, coated with a double membrane, up to 30 nm in diameter, in which the RNA molecule is located. On the surface of the virus particle there are thorns( villi) 6-8 nm in size, which contain hemagglutinin. Agglutination of erythrocytes of pigeons and geese, has hemolytic properties. Unlike other togaviruses, it contains neuraminidase. Pathogen for some species of monkeys. It is able to reproduce in many cell cultures, but cytopathic action is not manifested in all. Has a tendency to long-term chronic infection.

    Induces the formation of specific viral neutralizing, complement-binding, hemagglutinating antibodies. The virus is relatively unstable, quickly dies when heated( at 56 ° C), when dried, with changes in pH( below 6.8 and above 8.0), under the influence of ultraviolet rays, under the influence of ether, formalin, disinfectants. However, in the frozen state it retains infectious properties for several years.

    Epidemiology. The incidence of rubella in recent years has significantly decreased and amounted in 2009 to 1.14 per 100 thousand of the population. The share of children under the age of 17 accounted for 77%.

    The only and natural reservoir and source of the rubella virus is a sick person, but it is not always possible to establish this source, as in more than half of the cases rubella occurs in asymptomatic or erased forms. The source of rubella disease can be a child born from an infected mother. It is known that children with congenital rubella infection can be a source of the virus before the age of three, but cases of virus isolation with congenital rubella have been described for 18 years.

    The causative agent is transmitted by airborne and transplacental routes.

    There is a high susceptibility to the rubella virus, 80-90% of nonimmune individuals become infected when the infection enters the collective. Children of the first 6 months of life are insensitive to the rubella virus due to maternal antibodies. The highest incidence is registered among children aged 2-9 years. More often the disease occurs in the winter-spring period. After the transferred disease remains a persistent lifelong immunity. However, filed by R.E.Berman and VKVaughan( 1992), 3-10% of immune children may have recurrent rubella diseases.

    Rubella is seen only in children, especially between the ages of six months to two years, and is more common in spring and autumn than in other seasons. The disease does not pose a serious threat to health;after it there are no complications. Treatment is aimed at weakening the symptoms while they are available.

    Pathogenesis. Rubella virus enters the body through the mucous membranes of the upper respiratory tract. Then it penetrates into the regional lymph nodes. On the mucous membranes and in the lymph nodes, the virus multiplies, which is clinically manifested by catarrhal syndrome and lymphadenopathy. In the future, there comes a virusemia, the intensity of which is insignificant. Hematogenous virus spreads throughout the body, is fixed in lymphoid cells, causes focal dermatitis.

    Antibodies appear 2-3 days after rashes. This leads to the completion of viremia, the formation of immunity, recovery.

    Clinical picture. During rubella, the following are isolated:

    1. The incubation period is 13-23 days.

    2. Prodromal period - from several hours to 1-2 days.

    3. The period of rashes is 3-4 days.

    4. Period of convalescence.

    The prodromal period is not constant, lasts from a few hours to 1-2 days, is characterized by lethargy, a slight runny nose, a cough. The general or common status is broken a little. Body temperature is subfebrile or normal. An increase in the supernuminal and occipital lymph nodes is determined.

    The period of rashes is characterized by the appearance of a rash against a background of mildly expressed signs of intoxication, moderate or weak catarrhal phenomena from the upper respiratory tract and subfebrile body temperature.

    Rash small-stalky, appears simultaneously on different parts of the body. The primary localization of the rash is the face, extensor surfaces of the extremities, buttocks. The rash in the first day is fairly bright, measuring 2-4 mm in diameter, individual elements can merge( resemble measles).From the second day the rash pale, can acquire a point appearance( resembles scarlet fever).The rash disappears after 2-3 days, leaving no pigmentation and peeling.

    Immediately before skin rashes, the enanthem may appear. It is represented by separate pink specks on the soft sky, some of them merge, pass to the arches and the firm sky. The mucous cheeks and gums are not changed.

    Lymph nodes grow no less than 24 hours before skin rashes and are in this condition for a week or more. Pallid and occipital lymph nodes predominantly increase. But parotid, submaxillary, popliteal, axillary lymph nodes can increase. They are of elastic consistency, mobile, sometimes painful.

    Catarrh of the mucous membranes of the upper respiratory tract and conjunctiva is observed intermittently, weakly expressed, lasts 2-3 days.

    Symptoms of intoxication also occur non-permanently, are slightly expressed, quickly disappear.

    Body temperature may be normal or subfebrile, persists for 1-3 days.

    The defeat of other organs for acquired rubella is uncharacteristic, but in adolescents and adults there may be signs of polyarthritis: arthralgia, swelling and tightness in the joints, exudation in them. These changes last from a few days to 2 weeks and disappear without a trace.

    During one of the epidemics, 8% of the boys complained about the tests( Berman RE, Vaughan VK, 1992).

    The period of convalescence for rubella usually proceeds smoothly. Complications are rare. The most serious of them are encephalitis, meningoencephalitis or encephalomyelitis( one case for 5000-6000 cases).In addition, laryngitis can develop with laryngeal stenosis, otitis media, pneumonia, nephritis, polyarthritis( more often in older children, adolescents and adults), secondary autoimmune thrombocytopenia.~

    Congenital rubella. In cases of rubella( typical or atypical forms) of a pregnant woman, the virus through the bloodstream infects the epithelium of the chorionic villi, the endothelium of the blood vessels of the placenta, the emboli formed enter the fetal blood flow, infecting the cells of the embryo. As a result, fetal development stops, spontaneous miscarriage, stillbirth or the birth of a child with severe developmental defects - congenital rubella syndrome( CRS).Manifestations of the teratogenic effect of the rubella virus depend on the timing of pregnancy, the most dangerous in this respect are the first three months - the period of organogenesis. When a pregnant woman is infected during these gestation periods, congenital rubella is manifested by isolated or systemic developmental defects, as well as stigmas of disembryogenesis. In case of disease or contact of a pregnant woman at 24-27 weeks of gestation, meningoencephalitis, myocarditis, hepatitis, pneumonia and / or dysplastic changes in various organs can be detected in fetuses and deceased newborns.

    It is established that CRS at the time of birth is detected only in 15-25% of newborns born to mothers who had rubella during pregnancy. But after a few years, serious congenital pathology is defined already in 50-90% of children. This is due to the ability of the rubella virus to persist in the body, despite the presence of high titres of specific antibodies in the blood and CSF.Due to this, congenital rubella acquires a chronic course, the most severe manifestation of which is the development of subacute sclerosing panencephalitis( PSPE).

    Symptoms that may be present at birth include intrauterine growth retardation, low birth weight. The triad of congenital anomalies described in 1941 by Gregg includes a combination of heart defects, eyes and hearing impairment.

    Cataracts( one-sided or bilateral), microphthalmia, retinopathy, glaucoma, corneal opacity can be seen from the side of the eyes.

    Heart defects in congenital rubella may be different: non-healing of the arterial duct, pulmonary artery stenosis, aorta, aortic valve damage, interatrial and interstitial septal defects.

    Deafness is registered in 50% of newborns with congenital rubella, and in 30% of patients it develops later.

    In addition, there may be other malformations: micro- and hydrocephalus, non-softening of the soft and hard palate, spina bifida, cryptorchidism, hypospadias, hydrocele, pyloric stenosis, atresia of bile ducts, congenital hepatitis, etc. Usually developmental flaws are combined.

    Neurological disorders of varying severity are recorded in 80% of patients with CRS( oligophrenia, motor disorders, hyperkinesis and epileptic seizures, focal symptoms, schizophreniform syndrome, etc.).The most severe course of PSEs, the manifestations of which can appear in the first years of the child's life with the subsequent progression of violations of the intellect and motor disorders.

    Due to the polymorphism of clinical manifestations, the diagnosis of congenital rubella requires laboratory confirmation.

    Given the leading syndrome of spotted exanthema, acquired rubella must be differentiated with the following diseases:

    The diagnosis criteria for acquired rubella are:

    Mitigated measles occurs in children who received an immune globulin or blood products in the incubation period. The first signs of the disease occur after 14-21 days after contact with the measles patient.

    Clinical manifestations of mitigated measles and rubella are similar in many respects: both diseases proceed easily, accompanied by subfebrile body temperature, unprimed, instantaneously manifested by a rash. However, in measles, unlike rubella, there may be spots of Belsky-Filatov-Koplik( an optional sign for this form of measles) and light pigmentation, as well as a lack of an increase in the occipital and posterior lymph nodes.

    The main significance in the diagnosis of these two diseases has an epidemic history: an indication of contact with the measles patient and the administration of blood products or immune globulin.

    With scarlet fever, as well as with rubella, the rash appears momentarily on the 1st-2nd day of the disease, has a small-spotted( small-pointed) character.

    The difference between scarlet fever and rubella is the presence of tonsillitis( often with overlapping), intoxication, characteristic changes on the part of the tongue( "crimson" tongue), a favorite localization of the rash( mainly on the lateral surfaces of the trunk, in natural folds, absent in the nasolabial triangle).the appearance in the future of large-plate scaling. In scarlet fever, unlike rubella, submandibular, and not occipital lymph nodes increase. With scarlet fever there is no cough, runny nose.

    In pseudotuberculosis, as with rubella, the rash may be spotty in nature. However, unlike rubella, pseudotuberculosis is characterized by prolonged intoxication and fever, enlargement of the liver and spleen, presence of diarrhea( facultative symptom), a favorite localization of the rash( in the area of ​​hands, feet, head).With pseudotuberculosis, there is no isolated increase in the occipital lymph nodes. Often with pseudotuberculosis, arthralgia, myalgia, and abdominal pain are noted.

    The final diagnosis of pseudotuberculosis is based on laboratory tests: general blood analysis( leukocytosis, neutrophilia, left leukocyte shift, increase in ESR), serological reactions( revealing the growth of the titer of specific antibodies).

    Enterovirus exanthema and rubella have many common manifestations: one-time emergence and the disappearance of a spotted rash, the faintness of fever, intoxication and catarrhal syndrome.

    However, enterovirus exanthema, unlike rubella, is often accompanied by multiple organ dysfunctions( encephalic syndrome, myocarditis, splenomegaly, myalgia, diarrhea, etc.), for it is an uncharacteristically isolated increase in the occipital lymph nodes.

    Varicella and rubella must be differentiated only if a chickenpox develops a prodromal rash of spotted nature. A prodromal rash with chicken pox appears among the full health or against a background of subfebrile condition, it is not accompanied by catarrh of the upper respiratory tract. A typical bubble rash appears after a few hours( or at the end of the first day).From this moment, the assumption of rubella can be removed.

    The acquired form of cytomegalovirus infection differs from rubella by the presence of systemic enlargement of lymph nodes, hepato- and splenomegaly, and prolonged fever. With CMVI, the rash may be polymorphic( along with spotted elements there are papular, urtic, hemorrhagic), it appears on the 3-5th day of the disease. In addition, with CMV can be sialoadenitis.

    The acquired acute toxoplasmosis differs from rubella with more severe course, the presence of fever, hepato- and splenomegaly, lack of catarrh of the upper respiratory tract, the time of appearance of the rash( 4- 7th day).

    Trichinosis differs from rubella with more severe course, the presence of intense muscle pains, puffiness and swelling of the face, pronounced eosinophilia, lack of an increase in the occipital lymph nodes, catarrh of the upper respiratory tract.

    Trichinosis is diagnosed on the basis of epidemiological data - eating for 1-6 weeks before the first signs of a disease of raw or insufficiently thermally processed pork, meat of wild animals.

    Leptospirosis differs from rubella by the presence of severe intoxication and fever, muscle pain, the onset of rash( on the 3rd-6th day), frequent polymorphism of the rash( along with spotty there may be papular, urticaria and hemorrhagic elements), the presence of hepato- and splenomegaly,frequent damage to the kidneys, the possible presence of jaundice, the absence of an isolated increase in the occipital lymph nodes. The final diagnosis of leptospirosis is made on the basis of laboratory data: in the anaesthesia of the blood - leukocytosis, neutrophilia;in urinalysis - proteinuria, cylindruria, erythrocyturia;detection of specific antibodies.

    In infectious mononucleosis, unlike rubella, there is angina( often with overlapping), systemic lymph node enlargement, hepato- and splenomegaly, the rash can be polymorphic( along with spotted elements there are papular, urticaria, hemorrhagic), tend to merge. Infectious mononucleosis is characterized by prolonged fever and moderately severe intoxication. The rash with this disease often appears on the 3-5th day. Infectious mononucleosis is characterized by hematological syndrome: absolute lymphocytosis, monocytosis, the presence of atypical mononuclears.

    With Rosenberg infectious erythema, the rash appears on the 4th-6th day of the disease, at fever height( 38-39 ° C), the rash has a predominant localization on the limbs( extensor surfaces) and is almost completely absent on the face and trunk, in the following days the elementsRashes form erythematous fields. At the height of the disease, the liver and spleen often increase. The rash persists for 5-6 days, then in its place appears pancreatic or lamellar ecdysis. With infectious erythema, Rosenberg does not have an increase in the occipital lymph nodes.

    Clinical manifestations of rubella and postvaccinal reaction to measles vaccine are similar in many respects: the rash appears momentarily, rapidly disappears without a trace, is mainly spotty in nature. Differences between them consist in complete absence at a postvaccinal reaction of a fever and an intoxication, and also a lymphadenopathy. Help in the diagnosis of anamnestic data: an introduction a week before the appearance of rash vaccine against measles.

    Allergic dermatitis, unlike rubella, is accompanied by polymorphous rash: along with spotted elements, there are papular and urticarous formations accompanied by itching. For allergic dermatitis is not characteristic of intoxication, fever, catarrhal phenomena. They usually appear in children with an allergic phenotype after contact with a potential allergen( medicines, food, etc.).

    In contrast to rubella, the rash with pink lichen grows for 2-3 weeks, it is larger( up to 1.5 cm in diameter), in the center of the elements there is peeling. For pink depriving, fever, intoxication, and catarrh of the upper respiratory tract are uncharacteristic.

    In secondary syphilis, the main element of the exanthem is the spot. Unlike rubella in syphilis, the rash appears at normal temperature and the patient's satisfactory general condition, persists up to 2-3 weeks without dynamics, then disappears completely. With syphilis, there is no increase in the occipital lymph nodes.

    Specific laboratory tests are used to confirm the diagnosis of syphilis.

    The leading manifestations of congenital rubella are malformations, the cause of which can be the following congenital diseases:

    Specific laboratory diagnosis of rubella. Virological methods are effective in limited periods of the disease:

    Serological methods. The first virusinitralizuyuschie and inhibiting hemagglutination antibody. Revealed in the 1-2 day after the appearance of the rash, reaching a maximum level on the 6-20th day. Despite the subsequent decline, remain high for life.

    In subclinical and antipsychotic forms, antibodies are detected on the 14th-21st day after infection. These types of antibodies are detected in PH and RNGA.PH and RNGA are put with paired sera at intervals of 10-14 days, diagnostic is the increase in titer 4 times or more.

    The production of complement-binding antibodies begins early, but their level is low in comparison with virus neutralizing and hemagglutinating antibodies, they persist for no more than 3 years, they are detected in the DSC.Detection of complement-binding antibodies indicates a recent disease or a recovery period.

    The use of ELISA allows the detection of class-specific antibodies. The detection of IgM and IgA antibodies indicates the initial period of the infectious process, the class of IgG - in the acute period or the period of re-convolution, depending on their level and avidity. Newborns have increased susceptibility to infections and abnormal immunoglobulin content: a higher IgM content with a low IgA and IgG content.

    The vast majority of rubella patients receive treatment on an outpatient basis. Hospitalization is subject to patients with severe complications: encephalitis, encephalomyelitis, stenosing laryngitis.

    Treatment should be comprehensive:

    Treatment of complications is carried out according to the general principles of treatment of these conditions.

    Patients with congenital and acquired rubella, accompanied by neurological complications, need dispensary follow-up and long-term therapy.

    Rubella prevention should be based on the integrated use of interventions for sources of infection, transmission mechanisms and susceptibility of the population.

    Activities with respect to sources of infection are reduced to the identification and isolation of patients and the account of contactees.

    According to official instructions, a patient with rubella is to be isolated until the rash disappears, that is, up to the 4th day of illness.

    A child who has been in contact with a sickly rubella should not be admitted to children's institutions( kindergartens, children's homes, sanatoriums) within 21 days from the moment of separation from the patient.

    When a pregnant woman contacts a sick rubella, her susceptibility should be determined serologically. In the case of the presence of IgG, the woman is immune. In the absence of antibodies, the sample is taken again after 4-5 weeks. With a positive result, a woman is offered an abortion. If the second sample does not contain antibodies, the test is repeated in a month - the interpretation is the same as the second sample.

    Active and passive immunization

    In our country are registered:

    Vaccination against rubella is given to a child aged 12-15 months, revaccination at 6 years. The latter is necessary to protect children who are not vaccinated or who did not respond to the first vaccination. Unvoiced at an early age girls are vaccinated at 14 years.

    Dissolved drug is administered subcutaneously or intramuscularly at a dose of 0.5 ml.

    Post-vaccination reactions are extremely rare and usually exhibit a slight increase in body temperature, short-term catarrhal symptoms or the onset of hyperemia and infiltration at the site of administration, which may in some cases be accompanied by regional lymphadenopathy, short-term rashes, arthralgias and arthritis.

    Vaccination is contraindicated in children with immunodeficient conditions, hypersensitivity to aminoglycosides and egg protein( for MMR-II vaccination).

    Vaccination is performed at the end of an acute illness or exacerbation of a chronic, and not earlier than 3 months after the administration of human immunoglobulins. When immunoglobulins are administered earlier than 14 days after vaccination, the rubella vaccine should be repeated.

    It is strictly forbidden for women 3 months before the onset of pregnancy.

    In children's practice, passive immunization against rubella with immunoglobulin is not carried out.