Congenital rubella in schoolchildren and adolescents

Facial dysmorphism in congenital rubella syndrome

PURPOSE

To investigate the dysmorphic facial features in congenital rubella syndrome (CRS) and describe their associations with ocular and systemic features.

METHODS

The medical records of children diagnosed with CRS between 2016 and 2021 were retrospectively reviewed for ocular and systemic features. CRS was diagnosed either on the basis of positive serology for rubella antibodies or with the classic triad of congenital cataract, sensorineural hearing loss, and congenital heart defect. Children with photographic documentation of the face were analyzed independently by three experienced investigators for facial dysmorphic features (triangular face, microcephaly, broad forehead, low anterior hairline, whorl on the anterior hairline, prominent nose, micrognathia). The dysmorphic feature was recorded as present only when at least two of the three examiners confirmed its existence.

RESULTS

CRS was diagnosed in 237 children: mean age at presentation, 5.45 ± 4.5 years; 126 males (53%); bilateral cataract, 176 (75%). Positive serology for rubella antibodies was noted in 153 children (65%). Photographic record of facial features was documented in 127 (54%). The most common dysmorphic facial feature was wide forehead (82 [65%]), followed by low anterior hairline with whorl (41 [32%]). However, microcornea (P = 0.9801), cataract (P = 0.8342), pupillary sphincter atrophy (P = 0.7421), and salt and pepper retinopathy (P = 0.8803) were not significantly associated with the presence of facial dysmorphism. Congenital heart disease was significantly associated with facial dysmorphism (P = 0.0308). Sensorineural hearing loss was not associated with the presence of facial dysmorphism (P = 0.8463).

CONCLUSIONS

Facial dysmorphism is common in children with CRS, but it was not predictive of the presence of ocular manifestations of CRS in this cohort.

Novel facial characteristics in congenital rubella syndrome: a study of 115 cases in a cardiac hospital of Bangladesh

OBJECTIVE

To establish novel facial characteristics unique to congenital rubella syndrome (CRS) as prediagnostic criteria to supplement disease diagnosis in patients with or without a history of maternal rubella infection.

DESIGN

An analysis of 115 CRS case series (2018-2020) based on the presence of any of the triad features.

SETTING

Outpatient department of a tertiary care referral cardiac hospital in Dhaka, Bangladesh.

PARTICIPANTS

In total, 115 participants (53.1% men) were enrolled. Participants underwent echocardiography if they presented with suspected cardiac symptoms along with deafness, cataract or microcephaly.

MAIN OUTCOME MEASURES

Age, sex and socioeconomic status of the participants; history of maternal vaccination and infection; facial characteristics unique to CRS (triangular face, prominent nose, wide forehead and a whorl on either side of the anterior hairline) named 'rubella facies' and frequency of systemic involvements in CRS.

RESULTS

The median patient age was 2 years. The income of 50.4% of the participating families was <US$1500. Further, 32 mothers (27.8%) were infected with rubella during the first trimester of pregnancy, 15 (13.0%) during the second trimester and 3 (2.6%) during the third trimester. The remainder (65.2%) recalled no history of infection during pregnancy. Rubella facies presented as a triangular-shaped face in 95 (82.6%) cases, a broad forehead in 88 (76.5%) and a prominent nose in 75 (65.2%). A rubella whorl was present on the right or left side of the anterior hairline in 80% and 18.2% of cases, respectively. IgG and IgM antibodies were present in 91.3% and 8.6% of children, respectively. Cataract, deafness, microcephaly, and congenital heart disease were detected in 53.0%, 75.6%, 68.6% and 98.2% of cases, respectively.

CONCLUSIONS

Rubella facies, a set of unique facial characteristics, can support early CRS diagnosis and treatment and may supplement the existing CRS triad.

Systematic Review of the Manifestations of Congenital Rubella Syndrome in Infants and Characterization of Disability-Adjusted Life Years (DALYs)

Congenital rubella syndrome (CRS) continues to cause disability among unvaccinated populations in countries with no or insufficient rubella vaccine coverage to prevent transmission. We systematically reviewed the literature on birth outcomes associated with CRS to estimate the duration, severity, and frequency of combinations of morbidities. We searched PubMed, the Science Citation Index, and references from relevant articles for studies in English with primary data on the frequency of CRS manifestations for ≥20 cases and identified 65 studies representing 66 study populations that met our inclusion criteria. We abstracted available data on CRS cases with one or more hearing, heart, and/or eye defect following maternal rubella infection during the period of 0-20 weeks since the last menstrual period. We assessed the quality and weight of the available evidence using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Most of the evidence originates from studies in developed countries of cohorts of infants identified with CRS in the 1960s and 1970s, prior to the development of standardized definitions for CRS and widespread use of vaccine. We developed estimates of undiscounted disability-adjusted life years (DALYs) lost per CRS case for countries of different income levels. The estimates ranged from approximately 19 to 39 for high-income countries assuming optimal treatment and from approximately 29 to 39 DALYs lost per CRS case in low- and lower- middle-income countries assuming minimal treatment, with the lower bound based on 2010 general global burden of disease disability weights and the upper bound based on 1990 age-specific and treatment-specific global burden of disease disability weights. Policymakers and analysts should appreciate the significant burden of disability caused by CRS as they evaluate opportunities to manage rubella.

Hearing defects in children born of mothers suffering from rubella in the first trimester of pregnancy

The investigations concerned women that had suffered from symptomatic rubella in the first trimester of pregnancy. The presence of immunoglobulin G and immunoglobulin M antibodies in mothers and their children was detected, and the hearing organ was examined. In early childhood (up to 3 years of age), hearing loss was confirmed in 50% of the children born of mothers with rubella.

The use of tissue expanders in the reconstruction of orofacial defects secondary to congenital rubella: case report

A patient with a severe orofacial defect secondary to congenital rubella is described. The absence of the lower portion of the orbicularis oris muscle, the death of tissue in the infralabial region, as well as the presence of only a vestigial lower lip has hitherto not been reported in the literature. Tissue expanders were used to provide tissue for restoration of the deficient soft tissue of the submental region, a bipedicled flap from the upper lip was used to create a normal anatomic lower lip, and osseointegrated implants were used to stabilize a full denture prosthesis.

Teratogenic hearing loss

The total incidence of congenital defects, as reported by various authors, varies considerably with figures ranging from 1 to 3% depending on geographic locality and ethnic origin basis and only in a few percent the cause of the congenital defect can be traced to a known environmental factor. In contrast to other defects, congenital hearing impairment is often attributable to exogenous agents affecting the fetus during pregnancy. Nevertheless, in congenitally deaf children, the unknown etiological group remains the largest and here the most important object for future research is to recognize hitherto unknown exogenous agents, with the ultimate aim of preventing such causes of deafness. A brief survey is given on the present state of knowledge on the harmful effects of drugs and infections on the fetus's hearing organ, supplemented with some personal observations.

Abnormalities of the vas deferens and epididymis in cryptorchid boys with congenital rubella

Cryptorchidism was present in 12% of 316 boys with congenital rubella (CR) followed by The Roosevelt Hospital Rubella Project. Eight of these patients, age 4 through 16 yr, had a recent orchiopexy, 4 on the left, 2 on the right, and 2 bilaterally. The vasoepididymal system was absent or apparently obstructed in 60% of the 10 sides. The epididymis was abnormal in 6 instances and the vas deferens in 5. Sixty-one boys of the entire series had an intravenous pyelogram (IVP) that was significantly abnormal in 18%. The 8 patients described all had a normal IVP except for 2 who had a malrotated kidney on the involved side. In 5 of the 8, a known maternal rubella infection has occurred during the first 8 wk of gestation. As the rubella virus is known to interfere with cellular growth and tissue differentiation in early pregnancy, it apparently altered the developing testis and mesonephric duct system. Similar vasoepididymal abnormalities have been described previously in patients with uncomplicated cryptorchidism, inguinal hernia, kidney defects, cystic fibrosis and male sterility. Their presence should alert the clinician to perform an IVP and also consider a diagnosis of congenital rubella.

Rubella infection and diabetes mellitus

The incidence of diabetes mellitus was increased in patients with congenital rubella. Experimental congenital rubella infection in rabbits caused histological changes in the beta-cells of the pancreatic islets similar to those found in mice made diabetic by the M variant of the encephalomyocarditis virus. It is concluded that the diabetes seen in congenital rubella is due to viral infection of the pancreatic islet cells.

Progressive rubella panencephalitis. Late onset after congenital rubella

In children with congenital rubella infection the deficits remain stable; neurologic deterioration after the first few years of life is not believed to occur. We have encountered three patients with a definite or presumptive diagnosis of congenital rubella, in whom a progressive neurologic illness developed that began in the second decade and was characterized by spasticity, ataxia, intellectual deterioration, and seizures. High antibody titers to rubella virus in serum and spinal fluid were present in two, and all had increased cerebrospinal-fluid protein and gamma globulin. Extensive attempts to recover a virus from brain and body fluids were unsuccessful. The brains of two patients showed a widespread, progressive, subacute panencephalitis mainly affecting white matter. These data suggest that rubella virus may be a cause of progressive panencephalitis.

HL-A antigens in congenital rubella and the role of antigens 1 and 8 in the epidemiology of natural rubella

Study of 87 patients (53 adults, 23 males; 34 children, 18 males) with congenital rubella revealed an increased incidence of several HL-A antigens, including HL-A5, HL-A1, HL-A3 and HL-A8, the frequency of HL-A1 being raised because of the statistically significant increase of this antigen in the adult female subjects compared with normal controls. Correlation of the level of seropositivity to rubella virus in 29 normal adult populations, according to racial origin and geographic location, with the frequency of various HL-A antigens revealed the most significant association with HL-A1 (r equals 0.71). It is suggested that the presence on the cell surface of HL-A1 or the combination of HL-A1 and 8 may fovour rubella virus infection.

Clinical and social status of patients with congenital rubella

Eighty-five older patients with congenital rubella attending The Hospital for Sick Children were reassessed, paying special attention to their development and adaptation to their handicaps. They were a very handicapped group of children, nearly all were deaf, over two-thirds had ocular defects, and over half had cardiac defects. 15 children had a single defect. Abnormal finger patternings were present in 35%, but 21% of the mothers of these children had similar patterning. Only 9 children attended normal schools, the rest attended partial hearing units of residential schools for the deaf, and 24 children were in residential care for the mentally subnormal. Of the patients who had left school, 3 work in sheltered workshops, and 4 work as unskilled labour. No patient known to have had rubella antibody has lost antibody and there was no loss of immunological competence.

The ocular manifestations of congenital rubella

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