A 22-year-old unvaccinated woman comes to the office due to a rash that developed during a recent trip to Southeast Asia. A week ago, while still abroad, she developed a low-grade fever and arthralgias, followed by numerous pinpoint, pink macules and papules on her face. Over the next 48 hours, the rash spread to her trunk and then her extremities. She went to a local emergency department, where she was diagnosed with a viral illness and also found to be approximately 8 weeks pregnant. Her symptoms resolved over the following few days, and she returned to the United States. Physical examination today reveals postauricular lymphadenopathy. Heart and lung examinations are unremarkable. Fetal heart tones are normal. The fetus is at highest risk for developing which of the following complications?
Key features of congenital infections* | |
Toxoplasmosis |
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Syphilis |
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Rubella |
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Cytomegalovirus |
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Herpes simplex virus |
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*Nonspecific findings include growth restriction, jaundice, hepatosplenomegaly & blueberry muffin rash. PDA = patent ductus arteriosus. | |
This unvaccinated woman with a recent travel history developed a low-grade fever and a maculopapular rash with cephalocaudal spread, findings characteristic of measles or rubella. In this case, rubella is the most likely cause because polyarthritis/polyarthralgia, particularly in women, is a classic finding with acute infection. In addition, localized occipital and/or postauricular lymphadenopathy is more often seen in rubella.
Transplacental transmission of the rubella virus to the fetus during the first trimester causes congenital rubella syndrome. Sensorineural hearing loss, cataracts, and cardiac malformations (eg, patent ductus arteriosus) are classic manifestations in the affected infant. Growth restriction in weight, length, and head circumference (ie, microcephaly) is also common due to diffuse fetal inflammation.
Although treatment of suspected rubella infection is supportive care alone, the diagnosis should be confirmed in patients at risk for serious sequelae, such as pregnant women or newborns with classic findings. The presence of rubella IgM antibodies is diagnostic.
(Choice A) Epicanthic folds and brachycephaly are typical features of Down syndrome, a genetic disorder caused by an extra copy of chromosome 21, not by maternal infection during pregnancy.
(Choice B) Hydrocephalus and chorioretinitis are seen with congenital toxoplasmosis. Toxoplasma gondii infection in pregnant women is usually asymptomatic, but a nonspecific flu-like illness (eg, fever) with a maculopapular rash and lymphadenopathy can occur. In contrast to the diffuse onset of rash in toxoplasmosis, this patient's cephalocaudal progression of rash is characteristic of rubella. In addition, muscle aches (not joint pain) and cervical (not postauricular) lymph node swelling can occur in toxoplasmosis.
(Choice C) Meningitis and malformed teeth are consistent with congenital syphilis infection. In adults, secondary syphilis can present with constitutional symptoms (eg, fever, arthralgias), lymphadenopathy, and rash. However, lymphadenopathy is typically generalized, and the rash is classically present on the palms and soles.
(Choice E) Mucocutaneous vesicles and keratitis are manifestations of congenital herpes simplex virus (HSV) infection. In adults with HSV, head and neck lymphadenopathy can occur, but both primary and recurrent disease are associated with vesicular, not maculopapular, lesions that typically involve the oropharynx. Moreover, arthralgias are not seen.
Educational objective:
Maternal rubella infection classically causes a maculopapular rash with cephalocaudal progression, joint pain, and postauricular lymphadenopathy. Transplacental transmission to the fetus leads to congenital rubella syndrome, which is characterized by sensorineural deafness, cataracts, patent ductus arteriosus, and growth restriction (eg, microcephaly).