Invictus Reviews

Rubella In Question Form

• Mel Herbert

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Link to CXR Fundamentals Series on EM:RAP

We explore Rubella (German measles or three-day measles), a disease that remains clinically relevant despite being considered nearly eradicated in the US due to vaccination.

• Congenital rubella syndrome can cause severe complications including cataracts, cardiac abnormalities, growth restriction, and hearing loss
• Rubella typically presents with cephalocaudal rash, low-grade fever, and arthralgia 
• The disease is less severe than measles but still concerning for pregnant women
• Written documentation of at least one MMR dose is sufficient evidence of immunity
• PCR testing provides the most accurate diagnosis during acute infection
• Isolation period is seven days after rash onset to prevent transmission
• Rubella has a long 17-day incubation period with contagiousness spanning 7 days before and after rash
• Droplet precautions are appropriate for hospitalized patients
• Management of exposed pregnant women involves isolation and post-delivery vaccination
• Global vaccination coverage varies significantly, with lower rates in low-income regions

The full Invictus program is coming soon with continuous updates, comprehensive videos, MCQs, and resources to support physicians throughout their careers.


Speaker 1:

Hey party people, mel Herbert here for your free Invictus podcast. Before we get started, let's talk about a couple of things. On MRAP, we have released the Radiology Fundamentals series. You should go and watch that if you're an MRAP subscriber, and if you're not an MRAP subscriber, well, you should be. This is an amazing series done by Chris Riley. We shot it in the studio. It's super high quality. It will get you up to speed about how to read an x-ray, whether it's super high quality. It will get you up to speed about how to read an x-ray, whether you're a newbie or whether you have been doing this for quite a while. It is really exceptionally done. It is by far the best radiological series for um test x-ray reading that I've ever seen. And this is just the first of the beginning of a number of series that we're going to have coming out on trauma, on pediatric trauma, on slit lamps, on opmology and a whole bunch of stuff shot at the highest level for your dining goodness.

Speaker 1:

What else do I have to tell you about? Oh, asep. If you go on ASEP this year, after the keynote I will be with Joe Sex and Noah Wiley of the Pit and we're going to do a conversation about the Pit and how it's made realistic, and Noah Wiley's going to be there and it's going to be a lot of fun. So hopefully we'll see you at ACIP. Acip is early this year. It is in Salt Lake City and it's in early September. I've never been to Salt Lake City, so I'm excited to go and check out the tar. That is you. Now let us get actually. The other thing is, I should tell you, is it on the YouTube channel? I think I'm going to post a thing I did about IVIG. I'm fascinated by IVIG its indications how it works, when it works, when we should be thinking about it. So that'll be on the YouTube.

Speaker 1:

But now let's get into this episode and I want to talk about Rubella. So let's do it as a series of 10 questions and I think by the end of it we'll have a pretty good idea about Rubella. I should say this oh, I forgot to say this when I did my in-service exam back in the day, I got a pretty good score, and then, when I certified, I got a pretty good score. And then, when I recertified, I got a pretty good score. And then, when I recertified it, I got a passing grade. Thank you, and I think part of that is because I'm old and demented. But also in the last recertification there was a ton of pediatrics and I'd stopped seeing a lot of pediatric patients a few years before, and there was a lot on rashes, pediatric rashes and viral syndromes, and I frankly just forget that stuff if I don't go over it constantly. So this is one of those syndromes which we should talk about. There'll probably be a few questions on the exam and let's do it.

Speaker 1:

So what is the most common manifestation of congenital rubella syndrome? I know we're going to talk about rubella and all these questions are going to be on rubella, but this is just a way of learning about rubella rather than just reading it. So rubella back in the day was a terrible disease, mostly because of infections that occurred during pregnancy, and the rubella syndrome was associated with a significant amount of maternal death, with cataract issues, with encephalitis, with a whole bunch of bad things which would happen to fetuses, and so that's why, in order to get a marriage certificate, you had to have evidence that you had been vaccinated against rubella or had already had an infection. So it's a big deal for that reason In and of itself, if you're a little kid or an adult with rubella not that big a deal. Some people call this the three-day measles syndrome. So it's like measles but a lot less severe, except if you're pregnant. It's also called German measles.

Speaker 1:

So what is the most common manifestation of congenital rubella syndrome? A hearing loss, b cardiac abnormalities, c cataracts or D growth retardation. Which one do you think it is? The answer is cataracts. You don't really need to know this for the exam, but that congenital syndrome which is associated with cardiac abnormalities, growth restriction, death, cataracts all of these bad things, cataracts is the most common one. Now. Death cataracts all of these bad things. Cataracts is the most common one.

Speaker 1:

Now here's question. Two Six-year-old, unvaccinated child presents with a cephalocordial rash, starts in the head, goes down Low-grade fever, arthralgia After returning from Afghanistan. What is the most likely diagnosis? Measles, rubella, scallop fever, contact dermatitis Well, it could be measles or it could be rubella. But up fever contact dermatitis Well, it could be measles or it could be rubella. But since we're doing rubella, this is rubella. How do you tell the difference between rubella and measles? Mostly because the rubella syndrome is a lot less severe. Remember that we talked about measles. When you've got measles, you are miserable, you don't usually get as sick and it doesn't last as long when you have rubella.

Speaker 1:

Question three which of the following is considered evidence of rubella immunity? A history of rubella symptoms without laboratory confirmation. B born after 1965 with no vaccination records. C written documentation with at least one dose of MMR or. D negative IgM serology. And the answer here is written documentation about at least one MMR vaccine. So even if you just have had one of the two doses, you're considered to have significant immunity. Now the other things may include things like you've got laboratory evidence of immunity with an IgG. You have born prior to 1957, because then everybody had it. A history of symptoms without confirmation being born after 1965 or a negative IgM serology do not meet the criteria for whether you have prior immunity. If you want to know, you can do the IgG test to see if you've had it in the past or if you've had vaccinated and you forgot about it.

Speaker 1:

Question four what is the recommendation isolation period for a patient with confirmed rubella after the onset of rash? Is it three days? Is it seven days? Is it 14 days? Is it seven days? Is it 14 days? Is it 23 days? The correct answer is seven days. So you tend to be infectious for about seven days after it becomes obvious that you've got the disease. So you want to hide that person away for about seven days from the pregnant people, all right, or other unvaccinated persons, as it were.

Speaker 1:

Which diagnostic test is likely the most accurate for confirming acute rubella syndrome? So I've got this person, they've got the rash, they're heading down. What test could I do? Could I do IgG serology B? Could I do a PCR of nasal throat or urine samples? Could I do an IgM or could I do a CBC? And the answer is PCR. So if you're acutely sick and you want to know, there is a PCR and that is probably the best test during an acute sickness to make the diagnosis.

Speaker 1:

Here's question six A pregnant woman is exposed to a confirmed case of rubella. What is the most appropriate management? A administer MMR vaccine. B isolate her from pregnant stuff and vaccinate after delivery. C administer immune therapy. D no action. And the answer is isolate her from pregnant stuff and vaccinate after delivery. Now I actually don't know about immunoglobulin therapy for rubella, but now I do because I looked it up. So there is a Cochrane collaboration review that says that there is post-exposure passive immunization for preventing rubella and rubella syndrome that is available. So in that rare, rare circumstance where that comes up, this would be another option. The issue here is that rubella in the US was considered like a dead disease gone. Nobody has it, thank you very much. So this just doesn't come up that much, but maybe we'll see a return. But it turns out from the Copicurin collaboration they say that this passive hyperimmune globulin should help. The key thing with this one is isolation. Don't infect any more people. And then you vaccinate after delivery, usually 28 days after delivery.

Speaker 1:

Question seven which of the following complications of rubella is most likely to require airway management or ventral tree support? Florombo-cytopenic purpura that certainly occurs with rubella rarely, but you don't need to tube those people. Hepatic dysfunction absolutely concur with rubella syndrome, but you don't usually have to tube those people. Encephalitis absolutely occurs with rubella syndrome, but you don't usually have to tube those people. Encephalitis absolutely occurs with rubella syndrome Rarely, but does occur Obviously you might want to tube that person. And then D arthralgia. So the answer is encephalitis, but they get arthralgia as well. Okay, let's do.

Speaker 1:

Question eight what is the incubation period for rubella? Is it seven days, 12 days, 17 days or 23 days? Well, it's actually quite a long incubation period and it is about 17 days, and you're contagious for about 7 days before incubation and seven days after the rash. Let me say that again. So it's got a long incubation period, but you are contagious approximately seven days before the rash and seven days after the rash. So we already talked about that seven-day thing after the rash.

Speaker 1:

Question nine which region has the lowest rubella vaccination coverage according to the 2020 surveillance reports? The Africa region, the Southeast Asia region, the Western Pacific region or low-income countries? And again, this is not something you really need to know, but it's you know. It's low-income countries because they have less vaccination and that doesn't really matter where you are. Vaccine's good it turns out. Last question A patient with suspected rubella is admitted to the hospital.

Speaker 1:

Which precautions should be utilized? Contact precautions, droplet precautions, airborne precautions or standard precautions be utilized Contact precautions, droplet precautions, airborne precautions or standard precautions? And the answer is this is a droplet spread thing, so put on some masks on to everybody. It's not that infectious compared to measles, so droplet infections is considered sufficient and obviously keep your pregnant or potentially pregnant docs and nurses away from this patient if you can, if they're unvaccinated, okay. So that was a little bit about rubella done in a different way, done as mostly just you know questions.

Speaker 1:

What's happening with the full invictus? We are recording a lot of videos, we are editing a lot of videos, we are making a lot of mcqs, we are building a website. It's all happening as fast as we can. Great faculty. This is really going to be pretty cool, and the coolest thing is that we're going to continuously update it. We're going to continuously be involved with you. Emergency medicine is terrifying. You have to know so much and you have to know it for the rest of your career. And this little thing that we're creating it's going to help you pass your test, but I also think it's going to help you with your practice of ER and urgent care and all the things that you might be doing with your life. So, herbert, out for now. More soon, bye-bye.