Ringlet rubella
| Classification according to ICD-10 | |
|---|---|
| B08.3 | Erythema infectiosum |
| ICD-10 online (WHO version 2019) | |
Rubella or Erythema infectiosum (synonyms: Kinderrotlauf , fifth disease , English fifth disease , French mégalerythème épidémique ) is a contagious exanthemic disease that is caused by the parvovirus B19 .
Like rubella, rubella is one of the so-called childhood diseases , although adults can still get it. The infection often proceeds without any symptoms. Only some of the patients show the characteristic rash with butterfly-shaped facial reddening and ring-shaped extremity eruptions. Serious complications are very rare. There is no vaccination and no cause-related therapy.
history
The name "fifth disease" or "fifth disease" in the English literature was given to rubella by the efforts of doctors from the 17th century to differentiate and systematize the childhood diseases with skin rash (exanthema). The Viennese pediatrician and bacteriologist Theodor Escherich , who originally came from Ansbach, differentiated rubella from measles in 1896 and declared it to be an independent disease. After measles, scarlet fever and rubella, a “ fourth disease ” was described by Clement Dukes in 1900 , but this is no longer seen as a separate clinical picture. In 1905 rubella was first referred to as the "fifth disease", although the pathogen remained unknown for a long time.
In 1974 the Australian virologist Yvonne Cossart discovered surface antigen ( HBsAg ) structures that looked like parvovirus particles during routine electron microscopic examination of the blood of blood donors for the hepatitis B virus . Later research showed that it was a previously unknown human parvovirus. This small virus is named Parvovirus B19 after sample B19 in which it was found. In 1981 a connection with a disease could be established with the detection of a parvovirus B19 infection in patients with sickle cell anemia and the temporary stoppage of blood formation (an aplastic crisis ). Two years later, infections with parvovirus B19 were identified as the cause of rubella.
Pathogen
The non-enveloped DNA virus from the parvovirus family ( Parvoviridae ), whose subfamily Parvovirinae and the genus Erythrovirus, is the smallest virus that causes disease ( human pathogenic ) with a diameter of only 23 nm . Its genetic information consists of a single strand of DNA . There are three different genotypes, called genotype 1 to 3. The virus prefers to use progenitor cells of the red blood cells in the bone marrow for reproduction , because the red blood cells themselves have no nucleus and no tools for the replication of genetic material.
Epidemiology
The only reservoir for the pathogen is humans. The transmission occurs through droplet infection in direct contact, also through contaminated hands and in rare cases through infected blood products. Infectiousness is greatest in the first four to ten days after infection. This means that children in the rash stage are practically no longer contagious. The infection is believed to leave a lifetime of immunity .
The infection rate , i.e. the proportion of people who have already been through an infection, is around five to ten percent in preschool age and 60 to 70 percent in adulthood. Figures on maternal infections during pregnancy are not available, but they appear to be rare. With a confirmed infection of the mother, the risk of illness for the unborn child is around five to ten percent and is greatest with infections between the 13th and 20th week of pregnancy.
The time between infection and the onset of the first symptoms ( incubation period ) is usually four to 14 days (maximum three weeks). Virus excretion usually lasts from the fifth to the tenth day after infection. Therefore, the possibility of transmission is highest in the time before the first signs of illness appear.
Symptoms
In the majority of cases the infection is symptom-free and silent festivities (immunization in the case of symptom-free infection) take place. In other cases, flu-like symptoms are found without a rash.
The typical rash is only seen in 15 to 20 percent of infected people and begins with red spots on the cheeks that enlarge and confluence (confluence). Usually the mouth area is spared ( butterfly erythema ). The disease is therefore also known as "slapped cheek disease" in the English-speaking world. On the following days, reddish spots appear on the shoulders, upper arms, thighs and buttocks, sometimes slightly raised, which tend to flow together and fade in the middle. This creates characteristic garland-like patterns. These skin manifestations can be changeable and fleeting, but last for up to seven weeks. The general well-being is only slightly affected.
Vasculitic skin conditions strictly limited to the hands and feet have also been described in young adults .
Complications
Occasionally there is joint involvement with joint pain and joint inflammation, preferably of the small joints, especially in girls and young women. The symptoms last for two weeks to several months and go away on their own even without specific treatment.
Other complications can be explained by the viruses' particular preference for red blood cells or their precursor cells. In patients with chronic haemolytic anemia, for example, aplastic crises can occur in which the bone marrow temporarily no longer produces any red blood cells. Such an aplastic crisis caused by parvovirus B19 is often the first sign of spheroidal cell anemia . A rash is almost always absent in these patients.
In patients with congenital or acquired deficiencies in the immune system , the virus is not eradicated. This can lead to chronically recurrent anemia. Typically, no specific antibodies against parvovirus B19 are detectable in these patients .
pregnancy
During pregnancy , the parvovirus B19 one third of cases over the approximately placenta are transmitted (placenta) on the fetus. In children, the virus particularly attacks the cells that make up the erythrocytes (red blood cells) and ultimately destroys them. The hematopoietic cells in the liver and bone marrow are particularly affected, with the result that there is a sharp reduction in high-performance red blood cells and thus severe anemia in the unborn (around ten percent). Frequent side effects are hydrops fetalis (around ten percent), ascites , a drop in cardiac output (cardiac decompensation ) and, in the worst case, miscarriage or stillbirth (around nine percent, particularly high risk for infection between the 10th and 22nd Week of pregnancy).
The virus can possibly be detected prenatally in the child's blood or in the amniotic fluid , but this is not always successful. The same applies to the detection of antibodies and even a detection is partly not meaningful in the case of unborn babies. The control of the child's development by means of ultrasound examinations at relatively short intervals is therefore the means of choice for documenting the course of the infection. Particular attention should be paid to the formation of hydrops fetalis and other causes such as B. clarify the Rh intolerance so that an initiated therapy can take effect. In fetal anemia, therapy consists of giving a blood transfusion via the umbilical cord .
If the infection proceeds without complications, negative consequences (long-term damage) for the child are usually not to be expected; at present there is no evidence of a parvovirus B19-associated developmental disorder causing malformations in the child ( embryopathy ). Therefore, parvovirus B19 infection during pregnancy is not a sufficient indication for termination of pregnancy .
diagnosis
If the rash is typical, the diagnosis can be made based on the clinical symptoms. In diagnostically unclear cases, an acute infection can be detected by determining virus-specific antibodies in the serum . The detection of anti-B19 IgM is considered an indication of an acute infection. A reactive B19 IgM finding should be confirmed by direct virus detection of the viral DNA in the serum, especially during pregnancy, since the reactivity of the IgM test can be unspecific. In immunodeficient patients, the serological findings can remain negative; direct virus detection is also necessary here. In the case of severe or chronic courses after the initial infection of severely immunocompromised patients, for example after organ transplantation , direct virus detection may also be necessary in the bone marrow (after a bone marrow punch ). If the unborn child is infected during pregnancy, the specific IgM antibodies in the child's serum are often not (yet) detectable in the blood at birth. The proof of an intrauterine infection of the child can be made by direct virus detection in the amniotic fluid or more reliably in the umbilical cord blood .
Differential diagnosis
Rubella should be differentiated from other infectious diseases associated with a rash: scarlet fever , measles , chickenpox , rubella , three-day fever . Facial erythema also occurs with disseminated Borrelia infection (serologically detectable) or with lupus erythematosus .
prophylaxis
There is no vaccine. There is also no knowledge about the preventive effect of immunoglobulins . Children with chronic blood disorders are highly contagious over time. They must therefore be isolated. It must also be noted that parvoviruses are extremely stable and therefore thorough hand disinfection is necessary in order to avoid nosocomial infections.
therapy
There is no specific therapy. Symptomatic therapy is usually not necessary. Immunoglobulins should be used in patients with immunodeficiency , chronic anemia and virus persistence . If there is a fresh infection during pregnancy, weekly ultrasound checks are indicated. If there are signs of hydrops fetalis , intrauterine blood transfusions should be used to preserve the child's life and end the pregnancy successfully.
literature
- German Society for Pediatric Infectious Diseases eV (DGPI) (Hrsg.): Handbook of infections in children and adolescents. 5th edition. Thieme, Stuttgart / New York, ISBN 978-3-13-144715-9 .
- E. Weir: Parvovirus B19 infection: fifth disease and more. In: Canadian Medical Association Journal. 2005; 172, p. 743, ISSN 0008-4409
- NS Young, KE Brown: Parvovirus B19. In: New England Journal of Medicine. 2004, 350, pp. 586-597, ISSN 1533-4406
- ED Heegaard, KE Brown: Human Parvovirus B19. In: Clinical Microbiology Reviews. 2002, 15, pp. 485–505, ISSN 1098-6618 (full text online)
- Tino F. Schwarz: Ringlet rubella - as important as it was 20 years ago. In: Gynecology and Obstetrics. 2004; 4, pp. 31–34 (full text online)
- Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9–223, here: p. 66.
Web links
Individual evidence
- ↑ C. Dukes: On the confusion of two different diseases under the name of rubella (rose-rash). Lancet, London, 1900, 2, pp. 89-94. ( Link to the journal )
- ^ DM Morens, AR Katz: The "fourth disease" of childhood: reevaluation of a nonexistent disease. In: Am J Epidemiol. 1991, 134 (6), pp. 628-640. PMID 1951267 .
- ↑ YE Cossart, AM Field, B. Cant, D. Widdows: Parvovirus-like particles in human sera. In: Lancet. 1975, pp. 72-73 PMID 46024 , link to the journal
- ↑ M. Classen, M. Böhm (Ed.): Internal medicine. Elsevier, Urban & Fischer, Munich 2009, ISBN 978-3-437-42831-9 , p. 655.
- ↑ Th. Mertens, O. Haller, H.-D. Klenk (Hrsg.): Diagnosis and therapy of viral diseases - guidelines of the society for virology. 2nd Edition. Munich 2004, ISBN 3-437-21971-5 .
- ↑ German Society for Pediatric Infectious Diseases V. (DGPI) (Ed.): Handbook infections in children and adolescents. 5th edition. Thieme, Stuttgart / New York 2009, ISBN 978-3-13-144715-9 .
