A Clinically Diagnosed Congenital Rubella Syndrome and Congenital Cytomegalovirus Co-infection

Abstract

This is a case of a four-month-old female infant who presented with clinical manifestations of congenital rubella syndrome (CRS) -bilateral cataracts, poorly-dilating pupils, microcorneas, salt and pepper retinopathies seen after cataract extractions, bilateral sensorineural hearing loss, patent ductus arteriosus, microcephaly, history of blueberry spots and low birth weight, and positive serum IgM and IgG tests for rubella. The patient's mother also had prenatal rubella infection. However, the patient also presented with additional set of clinical findings not seen in recent patients with CRS and not commonly reported in literature: visual acuities of poor to no dazzle, bilateral choroidal thickening on ocular ultrasound that spontaneously resolved, optic nerve inflammation that became atrophic, vessel tortuosities seen after cataract extractions, bilateral subependymal cysts with lenticulostriate vasculopathy in basal ganglia, basal ganglia hyperintensity suggestive of calcification, and jaundice. These findings plus the overlapping clinical manifestations with CRS and the positive IgM and IgG for cytomegalovirus (CMV) made us consider a congenital CMV co-infection.CRS already causes significant childhood morbidity. Getting co-infected with CMV in utero worsens morbidity and makes management more difficult. This case presented a congenital co-infection of rubella and CMV and discussed the added challenges in their diagnosis and management.

Congenital Cytomegalovirus Infection Initially Managed as Congenital Rubella Syndrome

“…10 All three articles on CRS reviewed for this paper cited cataract as clinical manifestation, with one even specifying bilateral involvement. [7][8][9] Although Lu and Yang detected only CMV IgM and IgG in 10-11 patients of their 37 with bilateral cataract with no rubella antibodies, their positivity rates for CMV IgM and IgG in the control group were relatively close to the study group (IgM: 11.8% vs. 15.5%; IgG: 17% vs. 23.3%). 15 A case report of supposed cCMV documented bilateral cataracts as manifestation.…”

“…However, the delay in implanting the IOL, a cheap and optimal option for correction, can negatively affect visual rehabilitation despite using aphakic glasses as an alternative. 9 Despite being the leading infectious cause of congenital anomalies, only 5-15% of those infected by CMV show clinical manifestations. 10 Congenital CMV (cCMV) also presents with a clinical triad composed of jaundice, petechiae, and hepatosplenomegaly.…”

Comparison of Congenital Rubella Syndrome Cases at a Philippine Tertiary Hospital from 2009-2012 to 2019-2022

“…Coinfection occurs which can complicate management or may lead to clinical misdiagnosis. 12 , 13 The tests are also not readily available even in major cities. 6 This makes diagnosing CRS in the country mostly clinical, as evidenced by the low number of laboratory-confirmed cases in this study and Lopez et al’s as well.…”