C a s e R e p o r t _ _

G . E n d e r s , A . C a l m , J . S c h a u b

Rubella Embryopathy after Previous Maternal Rubella Vaccination

Summary: This report concerns a boy with congenital rubella infection and features of the classical and ex- panded rubella syndrome who was born to a mother who had been successfully vaccinated with Cendehill vaccine seven years previously. The diagnosis of rubel- la embryopathy was confirmed by demonstrat ing ru- bella-specific serum IgM antibodies using four differ- ent methods, by the persistence of rubella H A l and lgG antibodies in serum taken between three and eight months of age and by the isolation of rubella virus from throat secretion, urine and blood mononuclear cells. The child died at eight-and-a-half months of age. This case is discussed in relation to the persistence of vaccine-induced immunity with particular respect to the protective quality of low levels of antibodies against intrauterine infection in the event of re-infec- tion during pregnancy.

Zusammenfassung: R6telnembryopathie trotz friiherer h np.]hng der Mutter gegen Rdteln. Der Bericht betrifft einen Knaben mit allen Symptomen ciner klassischen und erweiterten R6telnembryopathie , der 1982 von ei- ner Mutter geboren wurde, die sieben Jahre frfiher mit dem Cendehil l-Impfstoff erfolgreich gegen R6teln geimpft worden war. Die Diagnose wurde dutch den Nachweis von r6telnspezifischen IgM-Antik6rpern in vier IgM-Testar ten und Persistenz der R6te ln -HAH- und IgG-Ant ik6rper in Blutproben, en tnommen zwi- schen dem 3. und 8. Lebensmonat , sowie durch Nach- weis von R6telnvirus im Rachensekret , Urin und Lym- phozyten gesichert. Das Kind verstarb im Alter von 8V2 Monaten. Der Fall wird in Relation zur Persistenz der dutch Impfung induzierten Ant ik6rper insbeson- dere auch zu dem Schutzwert der niederen AntikOr- perti ter gegentiber einer intrauterinen Infektion im Falle einer Reinfektion in der Schwangerschaft disku- tiert.

Introduction

Successful rubella vaccination of prepubcrtal girls and se- ronegative women of childbearing age together with ru- bella screening of all antenatal patients should make con- genital rubella a preventable disease. The success of vac- cination depends not only on the initial antibody re- sponse, but also on the persistence of antibodies during childbearing a g e , which prevent possible fetal infection in the event of re-infection during pregnancy. To date, little

is known about the outcome of pregnancy following re-in- fection in previously vaccinated women. We are reporting the case of a child with rubella embryo- pathy who was born to a mother who had been successful- ly vaccinated with Cendehill vaccine seven years pre- viously.

Materials and Methods Serologic: tests for Rubella: The hemagglutination inhibition test (HAl), the single radial hemolysis test (SRH) and two enzyme- linked immunoassays (ELISA Enzygnost Rubella, ELISA Ru- bazyme) for IgG and lgM antibody determination were employ- ed. Sucrose density gradient fractionation (SDG) and anti-~t he- madsorption inhibition (Hit) were also used for the latter. All of these tests have been described previously (1,2). Isolation studies for Rubella virus: Attempts to isolate the virus from throat secretion, urine and stool were performed in pri- mary green (Cercopethicus athiops) monkey kidney (GMK) cul- tures challenged with Echo virus 11. To isolate the virus from blood, peripheral monouclear cells (PBMC) were obtained from hcparinized blood by Ficoll-Hypaque density gradient centrifilg- ation (3). Following stimulation with phytohemagglutinin for three days, the PBMC were co-cultivated with subconfluent monolayers of GMK cells and later challenged with Echo virus type 11. In all instances, two to four passages were carried out with the supernatant. The rubella virus isolates were identified by neutralization with rabbit anti-rubella hypcrimmune serum in GMK cultures.

Case Report

Mother: R.H., 28 years of age, third gravida, had an uneventful pregnancy in 1981/82. A retrospective investigation revealed that during her first pregnancy in 1974, she was seronegative for rubella and was vaccinated after delivery in November 1974 with Cendehill vaccine. An antibody test done nine weeks later gave an HAl titer of 1:32. No further test was done during the second pregnancy in 1976. During her third pregnancy in 1981/82, a ru- bella test was performed during the fifth month and an HAl titer of 1:64 was recorded. Two and three months after delivering the child L.H., a titer of 1:64 was again found in the mother's serum by the same laboratory which had done the previous test. How- ever, further investigation in our laboratory of a blood sample taken from the mother three months after delivery revealed an HAI titer of 1:256; antibody findings with increased tgG values are recorded in Table 1. On inquiry, the mother did not re- member having had any contact with rubella cases or rubella-

Received: 18 October 1983/Accepted: 24 November 1983

Prof. Dr. Gisela Enders, Virologisch-med. Diagnostisches lnstitut, H61- dcrlinplatz 10, D-7000 Stuttgart 1 ; Dr. A. Calm, Prof. Dr. J. Schaub, Abteihmg Allgemeine P~diatrie im Klinikum der Christian Albrechts-Universit/it Kiel, Kinderklinik, Schwanenweg 20, D-23(~) Kiel.

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G. Enders et al.: Rubella Embryopathy after Previous Maternal Rubella Vaccination

Table 1: Rubella embryopathy after previous maternal ru- bella vaccinatation.

IgG tests - Rubella HAI titer 1 : SRH diameter (mm) ELISA E titer 1: ELISA R index

IgM tes ts- Rubella SDG short HAl

long HAl ELISA E titcr 1: ELISA R index HIT titer 1 :

Virus isolation - Rubella Throat secretion Lymphocytes (PBMC) Urine Stool

256 13-14 8192 2.63

Negative Negative Negative Negative Negative

m

Negative

64 8-9

4096 1.47

Positive Positive

2048 4.58 1280

Positive Positive Positive Negative

32 5-7 1024 1.12

Positive Positive

2048 4.14 1280

Positive

H A I = Hemagglutination inhibition test; SRH = Single radial hemolysis test; SDG = Sucrose density gradient fractionation; HIT = hemadsorption inhibition; PMBC = Peripheral mononuclear cells.

like symptoms during her pregnancy. However, the frequency of rubella infection in most parts of Germany was high during her pregnancy. Child: The boy, L.H., was born on the 1st of June 1982, (weight: 2500 g). During the first days of life, signs of general in- fection with petechial bleeding and hepatosplenomegaly were apparent. Laboratory findings showed an Rh-positive (D+) blood group and an increased concentration of total IgM (90 mg/dl). Within five days, the platelet count declined from 96,000 to 54,000 and haemoglobin from 20. t g/dl to tl .6 g/dl. There were no antibodies to Treponema pallidum, Toxoplasma gondii, Cytomegalovirus or Listeria. All bacteriological investi- gations were negative. At the age of one to one-and-a-half months, the values obtained from liver function tests (SGOT, SGPT and Gamma GT) were slightly increased. Serology for hepatitis A and B was negative. Diagnostic investigations during the third to fourth months of life in the Children's Hospital of the University of Kiel revealed the following results: a) Clinical: Dystrophy, growth and motor retardation, bilateral cataracts, deafness, microcephaly, slight pulmonal stenosis, heart murmur (systolicum), hepatosplenomegaly and bone ra- diolucencies of the tibiae. The cataracts were successfully ope- rated at three-and-a-half months of age. b) Laboratory: The rubella serology of four sera taken in the 9th, 10th, 13th and 14th weeks of life and tested in four different laboratories gave HAl titers of 1:16, 1:32 or 1:64 and high-posi- tive, rubella-specific IgM antibody results with various methods. At the age of three months, rubella virus was isolated from the throat secretion, urine and PBMC. A genetic analysis carried out by the Department of Transfusion Medicine and Immuno-

haematology of the University of Kiel verified R.H. as being the mother of the child. The child was seen again in the outpatient department at the age of seven-and-a-half months when a further blood sample was taken. Rubella serology using several different tests showed the characteristic pattern of a severe case of rubella embryopathy. There was persistence of high-level rubella-specific IgM and some decline in the HAl titer and the IgG antibody test values. Rubella virus was also isolated from the PBMC (Table 1). In February 1983, at eight-and-a-half months of age, the boy showed signs of severe meningitis. He was admitted to the local children's clinic where he died two days later due to a massive pneumococcal meningitis.

Discussion

The clinical features and laboratory findings observed in L.H. , born in June 1982, are compatible with intrauterine rubella infection and rubella embryopathy. The clinical manifestations indicate that maternal rubella infection must have occurred in the first tr imester of pregnancy. The possibility that L.H. was not the child of the mother R.H. was excluded by genetic analysis. The case history shows how long it may take for an etiological diagnosis of rubella embryopathy to be made and that rubella serol- ogy, including IgM tests, should be carried out more rou- tinely in small for date and/or symptomatic newborns. In view of the maternal vaccination history, including a negative HAI trier of less than 1:8 (1 :<8) before and 1:32 nine weeks after vaccination with Cendehill vaccine, im- munity could be assumed. In various vaccine surveillance studies of vaccinated prepubertal girls and adult women tested for seven to sixteen years after vaccination (1,4-8), it has been shown that more than 92% of adult female vaccinees still possess HAI antibodies, although three studies show 16 to 20% of the vaccinees to have antibod- ies below the accepted minimum immune level of 15 IU (6-8). In women of similar age with natural immunity, low-level H A I antibody is seen in only 9% (8). It is also known that re-infection with rubella may occur at a low frequency after previous natural rubella infec- tion; this frequency is much higher after previous vacci- nation, however (1, 4, 9), and increasingly so with time. Re-infections in normal individuals tend to be asympto- matic (1, 10-14), but they may also be associated with rash and arthralgia (15-18). They are serologically characteriz- ed by a booster effect on the H A I and IgG antibody titers and sometimes also by a modera te IgM antibody response if the serum happens to have been obtained in the first four to six weeks after re-infection (15-17, 19). From the serological results obtained from the maternal blood two months after delivery showing increased ant ibody values in various tests, in contrast to the initial ant ibody titer of 1:32 seven years previously, it may be assumed in our case that the intrauterine infection and rubella embryopa thy were caused either by asymptomatic re-infection of the mother in the presence of low-level ant ibody or by an asymptomatic infection in the absence of protective anti- body. Neutralizing antibodies in similar cases of naturally

Infection 12 (1984) Nr. 2 © MMV Medizin Verlag GmbH Mtinchen, Miinchen 1984 57 / 97

G. Enders et al.: Rubella Embryopathy after Previous Maternal Rubella Vaccination

"immune" mothers were not present, in spite of the pre- sence of low HAl antibodies (11, 12, 16). Since neutraliz- ing antibodies were not measured in our case in the serum sample obtained following vaccination, an impairment of antibody function cannot be ruled out. In general, howev- er, tests for HAl antibodies, particularly if substantiated by other IgG tests now available, presumably measure the same antibody quality as the neutralization test which is difficult to perform (1, 20). It has been assumed that re-infection in the presence of low-level antibody after natural rubella and vaccine-ac- quired immunity is not associated with viremia. However, there are some reports in the literature suggesting that vi- remia can be present in re-infection and may be followed by transmission of the virus to the fetus (11-14, 18), which

may cause damage to the child. The detection of viremia following intranasal challenge with RA 27/3 vaccine in a vaccinee and in persons with natural immunity and low antibody levels shows that viremia can occur following ex- perimental re-infection (21, 22). Thus, if natural re-infec- tion in women with vaccine-induced immunity occurs dur- ing early pregnancy, it might provide a potential risk to the fetus. The case report presented here is hopefully an excep- tional phenomenon. However, more knowledge on the persistence and the protective quality of the vaccine-in- duced low-level antibody is needed, since the English and German rubella vaccine strategy' exposes pregnant wom- en to circulating wildvirus through their close contact with young children (23, 24).

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