Abstracts Of Selected Articles

The following is an abstract of an article, "Some Recently Recognized Manifestations of the Rubella Syndrome," by Stanley A. Plotkin, M.D., et al. This article appeared in the Journal of Pediatrics, 67:182-191, August 1965.

As a consequence of an epidemic of rubella which reached a peak in the spring of 1964, an upsurge in congenital anomalies occurred in Philadelphia in late 1964 and early 1965. An unusual characteristic of the occurrence was the large number of babies born with thrombocytopenic purpura, enlargement of the liver and spleen, and abnormalities of the long bones, In addition to the more typical opthalmologic and cardiac defects.

In his report Dr. Plotkin describes a series of 21 infants on whom virologie studies were conducted.

This study emanated from the Wistar Institute, Children's Hospital of Philadelphia, Hospital of the University of Pennsylvania, Fitzgerald Mercy Hospital and Woman's Medical College.

The mothers of these infants contracted rubella in the first trimester of pregnancy. Fifty-seven percent of the children weighed less than 2,500 gm. at birth. They had the following incidence of disease: ocular defects, 76 per cent; cardiac malformation, 67 per cent; both ocular and cardiac diseases, 52 per cent; thrombocytopenic purpura, 43 per cent; and hepat?-splenomegaly, 33 per cent.

Roentgenographs examination also revealed that seven (33 per cent) of these children had abnormally appearing long bones. (Since X-ray films were not obtained for each child, the estimate that one-third of the children had bone abnormalities is probably low.) The mechanism of the bone lesions is obscure. They may result from a disturbance of calcification due to generalized fetal infection such as seen in congenital syphilis. In this connection it is interesting that one of the severely affected infants in the Philadelphia series had roentgenographs evidence of calcification of the major arteries of the lower limbs.

The striking bone changes, seen in three of the cases, are described as typifying the larger group. These bone changes have not been recorded in the rubella syndrome prior to the epidemic of 1964-1965. Among the abnormalities were disturbed trabeculation of the metaphyses and mottling produced by juxtaposition of areas of increased density with areas of radio-lucency. In one patient the radiolucent areas were arranged with their long axes perpendicular to the epiphyseal plates, which were normal except for marked irregularity at the knee joints. In a second patient roentgenographs examination of the long bones showed slight irregularities in the trabecular pattern at the distal ends of the femora and humeri. In a third patient the distal metaphyses of both femurs exhibited a striking "motheaten" appearance, which however showed improvement when the patient was re-examined at five weeks of age.

Rubella virus was isolated from the nasopharynx of 19 of these infants. In the two infants from whom the virus were not isolated, specimens were not obtained until the infants were two months of age.

Five of the 21 infants showed signs of disease of the central nervous system.

The findings of this investigation were compared to those of a similar study in Houston 1). The Houston data were quite similar with respect to low birth rates and the unexpected frequency of thrombocytopenic purpura, hepatosplenomegaly, as well as the significant roentgenographs changes in the long bones seen in a relatively large number of children. However, the incidence of abnormalities differed. In the Houston study, thrombocytopenic purpura, hepatosplenomegaly, and roentgenographs changes in the long bones occurred in 60 to 80 per cent of the infants, about twice as frequently as in the Philadelphia study. Also, the Houston investigators noted more neurologic findings suggestive of encephalomyelitis. In the Philadelphia study more ocular and cardiac defects were seen (76 versus 44 per cent).

Dr. Plotkin comments that the thrombocytopenic purpura, hepatosplenomegaly, and other symptoms previously not associated with this syndrome may have been due to a rubella virus strain of greater virulence than had been encountered previously.

Co-authors of this report are Drs. Frank A. Oski, Eugene M. Hartnett, Arturo R. Hervada, Sidney Friedman, and Jean Gowing.

Shirlee Kempner

Abstracts Of Selected Articles

(The following abstracts from the November 1965 issue of Birth Defects are reprinted with the permission of the National Foundation - March of Dimes.)

Rubella Syndrome After Inapparent Maternal Illness.

Amer. J. Dis. Child. 110(4):444-446, Oct. 1965.

Avery, G.B. et al. (2121 13th St., N.W., Washington, D.C. 20009.)

Rubella was proved by virus isolation (most commonly from the throat) in 14 malformed infants with the classical features of rubella syndrome.

Twelve of the 14 mothers gave a history of exposure to rubella in the first trimester, but only 7 had developed clinical illness.

Thus rubella virus can apparently cross the placenta and affect the fetus without there being clinical evidence of maternal infection. (10 references.)

Rubella Epidemic, 1964: Effect On 6,000 Pregnancies. I. Preliminary Clinical And Laboratory Findings Through The Neonatal Period: A Report From The Collaborative Study On Cerebral Palsy.

Amer. J. Dis. Child. 110(4):395-407, Oct. 1965.

Sever, J.L., Nelson, K.B. And Gilkeson, M.R. (Nat. Inst. Neurol. Die. Blindness, Bethesda, Maryland 20014.)

A total of 6161 women was studied from the time of registration at the prenatal clinic of one of the collaborating hospitals through the end of the neonatal period of the offspring (28 days). Analysis of a special rubella questionnaire showed that 750 women had clinical rubella during pregnancy or were exposed during the first trimester.

Exposure to rubella during the first trimester was reported by 10% of the population. Clinical rubella occurred in 2% of which 407. were in the first trimester.

Clinical rubella in the first trimester resulted in a child with congenital rubella syndrome in 10%. First trimester exposure but no clinical illness resulted in a child with congenital rubella syndrome in 0.6%; in addition, prematurity was significantly increased.

Two of ten infants with congenital rubella syndrome had chronic infection with rubella; chronic infection was suspected in an additional seven.

Clinical diagnosis for rubella was corroborated serologically in 74% of cases tested. Inapparent infection occurred in 6% of women exposed but without clinical disease.

Known first trimester exposure resulted in clinical rubella in 37. and inapparent rubella in 67. based on serological tests. (25 references.)

References:
1 Rudolph, A.J., Yow, M.D., Phillips, C.A., Desmond, M.M., Blattner, R.J., and Melnick, J.L.: Transplacental Rubella Infection in Newly Born Infants, J.A.M.A. 191:843, 1965.