Dermatologic Manifestations of Rubella Clinical Presentation

Updated: Aug 10, 2017
  • Author: Peter C Lombardo, MD; Chief Editor: Dirk M Elston, MD  more...
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Studies on children at the New York Willowbrook State School in 1963, shortly after the isolation of the rubella virus, have shown that the disease is spread by nasal droplet infection and has an incubation period of 14-19 days, with onset of a rash usually on the 15th day. [9] The disease can be spread from a few days before to 5-7 days after the appearance of the exanthem. The virus can be detected in the pharynx from 7 days before until 7 days after the rash. A viremia was detected from 7 days before until the day of the rash, and the virus was present in the stool from 4 days before until 4 days after the rash. Isolating the virus from children with subclinical infections was also possible.

Patients are most contagious when the rash is erupting. Rarely, the virus may be shed from the pharynx up to 15 days after the appearance of the rash, in rapidly diminishing amounts, and it is very difficult to detect by culture after 5-7 days. Patients are not considered clinically contagious after 7 days.

Infection usually confers lifelong immunity, but reinfection is occasionally detected serologically after the natural disease or a vaccination upon reexposure to the virus and rarely results in clinical disease.


Physical Examination

In children, a prodrome may not be present. The rash may be the first manifestation. In adults, fever, sore throat, and rhinitis may be present. The exanthem begins as discrete macules on the face that spread to the neck, the trunk, and the extremities. The macules may coalesce on the trunk. Appearance of the rash corresponds with the appearance of the rubella-specific antibody. The exanthem lasts 1-3 days, first leaving the face, and may be followed by desquamation. On occasion, a nonspecific enanthem (Forchheimer spots) of pinpoint red macules and petechiae can be seen over the soft palate and the uvula just before or with the exanthem. Note the images below.

Young adult with macular rash. Young adult with macular rash.
Child with generalized eruption. Child with generalized eruption.

The hallmark of rubella is the generalized, tender lymphadenopathy that involves all nodes, but which is most striking in the suboccipital, postauricular, and anterior and posterior cervical nodes. It is most prevalent at the time of appearance of the exanthem but may precede it by a week. The tenderness that accompanies this lymphadenopathy subsides rapidly; however, the enlargement may last days or weeks.

Although less common in children, in adults, polyarthralgia and even polyarthritis may occur and rarely may persist longer than 2 weeks. It may resemble rheumatic fever or rheumatoid arthritis, with small and large joints being involved bilaterally with or without swelling. The swelling can be very marked. Fifty percent of women may have arthralgias, and 10% have arthritis, 3 days post rash with the natural infection or within 2-6 weeks after a vaccination.

Rarely, recurrent episodes of inflammation of the fingers, the wrists, and the knees can continue for more than a year. Very rarely, a syndrome of low-grade fever, chronic fatigue, and myalgias can persist for months or years. The pathogenesis of the arthritis is not known. The virus can be isolated from joint effusions in acute and recurrent cases. Peripheral blood mononuclear cells may harbor the rubella virus in chronic arthritis. Test results for rheumatoid arthritis are negative.



Rubella is an RNA virus classified as a Rubivirus in the Togaviridae family.



Complications are rare with rubella in healthy infants and adults. Rarely, encephalitis or peripheral neuritis may occur; however, recovery is usually complete without sequelae. Thrombocytopenia usually resolves within a month, but it may result in purpura, epistaxis, and intestinal bleeding.

Congenital rubella syndrome (CRS)

This the most severe and important complication of rubella and occurs in the fetus of a pregnant woman without immunity to the virus. Of infants infected in the first trimester, 50% are affected, and the severity depends on how early the infection occurs. Note the following:

The most common abnormalities are ophthalmologic in nature (eg, cataracts, retinopathy).

Cardiac abnormalities (eg, patent ductus arteriosus, pulmonary stenosis) may be seen.

Auditory involvement may be present as sensorineural deafness.

Neurologic disorders (eg, meningoencephalitis, mental retardation with behavioral disorders) may occur.

If infection occurs after organ development, a variable picture may be seen, with hepatitis, splenomegaly, pneumonitis, myocarditis, and/or osteomyelitis.

If the bone marrow is affected, thrombocytopenia with purpura and petechiae occur. Bizarre purple macules and papules, which represent persistent dermal (extramedullary) hematopoiesis, are seen in the skin. This appearance is known as blueberry muffin baby. Note the image below.

Blueberry muffin newborn with lesions on the foreh Blueberry muffin newborn with lesions on the forehead.

An infant who is affected may continue to shed the virus for up to 1 year. At least 85% of infants who are affected shed the virus at 1 month, and 1-3% do so at 1 year. Therefore, these individuals should be considered contagious for at least 1 year and should be considered an exposure threat to nonimmune pregnant women, unless nasopharyngeal or urine culture results are repeatedly negative.


No adequate treatment is available for pregnant women exposed to rubella. Immunoglobulin is not recommended unless termination of the pregnancy is not an option because cases of congenital rubella syndrome have occurred in infants born to mothers who received immunoglobulin shortly after exposure.