Sex: M
Vaccine: MMR
Symptoms: Hepatosplenomegaly, Immunology test, Lymphocyte morphology abnormal, Macrocytosis, Microcephaly
Clinical narrative: This literature marketed retrospective pregnancy report as received from a physician refers to a male child patient of unknown age. Information was received from a published article. A case of congenital rubella syndrome in a child born to a vaccinated woman who had not traveled internationally. In 2008, a full-term boy was born with microcephaly and a petechial rash. The infant's mother reported no rash illness, travel history, or known contact with ill persons during the first 4 months of pregnancy. She lived with her 2 other children and the case-patient's father, who had not traveled internationally during the mother's pregnancy. In 2002, the case-patient's mother had an equivocal rubella virus IgG titer of 5 and in 2003 received M-M-R II vaccine. Vaccination status of the father was unknown. Maternal rubella virus IgG titer at 4 months' gestation was >400 IU/mL. The infant was delivered by urgent cesarean section because of cardiac decelerations during labor. Apgar scores at 1 and 5 minutes were 9 (of 10 total). At birth, the child weighed 2.7 kg (10th percentile), and he was 48.25 cm (15th percentile) in length and had a head circumference of 31.75 cm (<3rd percentile). He had a petechial rash on the face, back, and upper extremities and a systolic heart murmur. No jaundice or hepatosplenomegaly was noted. Initial tests showed a leukocyte count of 13.8 x 10^9/L with atypical lymphocytes; a hemoglobin level of 202 g/L; abnormal erythrocyte morphology, including macrocytosis, polychromasia, and poikilocytosis; and a platelet count of 98,000 x 10^9/L. Computed tomographic scan of the head revealed 2 small calcifications in the left corona radiata. Results of neonatal hearing screening were normal. Urine samples were cultured for cytomegalovirus (CMV), and serum samples were tested for toxoplasma and parvovirus IgM; all results were negative. The infant was discharged from the hospital on day 4 with a suspected congenital infection. At 16 days of age, the child was seen by an infectious disease physician. Examination revealed hepatosplenomegaly, and the systolic heart murmur was detected across the precordium, with radiation to the back. CMV quantitative PCR and testing for lymphocytic choriomeningitis IgM and IgG were requested, but not obtained. Congenital rubella was considered, but serologic tests were not ordered. A subsequent echocardiogram demonstrated supravalvular and peripheral pulmonic stenosis, a small patent ductus arteriosis, and a patent foramen ovale. The child was delayed in attaining developmental milestones. At 6.5 months of age, he was referred to a geneticist, who requested multiple tests, including tests for rubella, CMV, and lymphocytic choriomeningitis. Rubella virus serum IgM was 7.2 and IgG was 59 IU/mL. The local health department received notification of the test results and immediately initiated an investigation in collaboration with the state Department of Health. During multiple interviews, the child's family denied any exposure to international travelers or persons with a rash illness during the potential exposure period. No source contact or secondary transmission was identified. State Department of Health and the infectious disease physician requested that the child not attend day care and avoid exposure to unvaccinated infants until after his first birthday, when he would be presumed to be free of infection. MMR vaccination at 12 months of age was withheld until completion of additional diagnostic testing. When the infant was 7.5 months of age, rubella virus RNA was detected from a nasal wash sample by using reverse transcription PCR (RT-PCR); results of a nasal wash culture and serum RT-PCR were negative. CDC culture and RT-PCR results for nasal samples collected when the infant was 10 and 12 months of age were also negative. However, ELISAs performed by CDC on a serum sample collected when the infant was 12 months of age confirmed the presence of rubella virus IgM antibodies (Diamedix Rubella IgM Capture EIA) and IgG antibodies (Wampole Rubella IgG ELISA II); results were 2.43 and 5.9, respectively. On an unknown date the child was exposed to M-M-R II via transplacental route, invitro. No concomitant medications were reported. On an unknown date the patient experienced congenital rubella syndrome. Criteria of the council of State and territorial Epidemiologists (2009) met by patient with confirmed case of congenital rubella were congenital heart disease, microcephaly, developmental delay hepatosplenomegaly (clinical) and laboratory criteria were demonstration of rubella IgM, persistent rubella antibody in an infant and positive rubella RT-PCR. The action taken with the therapy with M-M-R II was unknown. The outcome of the events was unknown. The reporter considered the event to be related to the therapy with M-M-R II. This case is linked to case number 1409USA007156 via mother baby link. Additional information has been requested.