Journal of Clinical Virology 56 (2013) 93–95 Contents lists available at SciVerse ScienceDirect Journal of Clinical Virology j ourna l ho mepage: www.elsevier.com/locate/jcv Virology Question and Answer Scheme (VIROQAS) Intermittent rash, lymph node swelling, arthralgia and vaccinal viral detection after rubella immunization Felipe Augusto Souza Gualberto a,∗ , Suely Pires Curti b , Maria Isabel de Oliveira b , Dewton Moraes-Vasconcelos c , Cristina Adelaide Figueiredo a,b,c a Faculdade de Medicina da Universidade de São Paulo, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, Brazil b Instituto Adolfo Lutz, Núcleo de Doenc ¸ as Respiratórias, São Paulo, Brazil c Faculdade de Medicina da Universidade de São Paulo, Laboratório de Investigac ¸ ão Médica em Dermatologia e Imunodeficiências, São Paulo, Brazil a r t i c l e i n f o Article history: Received 17 April 2012 Received in revised form 19 July 2012 Accepted 30 July 2012 Case presentation A 26-year-old woman was immunized on August 2008 with the rubella/measles vaccine (MR, Serum Institute of India). She had been in good health previously, with no medical history of any rheumatologic affection. The patient had already been vaccinated against rubella two years before, in an immunization campaign that occurred in Brazilian the state of São Paulo, and had no adverse reactions. She inadvertently took the vaccine again in the national campaign in 2008. Five days after the most recent vaccination, she developed fever, retroauricular lymph node swelling, erythema- tous maculopapular rash on her trunk, back, abdomen, forearm and ankle. On the subsequent days, she had arthralgia and a slight swelling in small joints of the hands and feet. The fever resolved in ten days but the rash on her back progressed to persistent hyperpigmentation, which also occurred over the joints of some fingers. Over the subsequent 18 months, the patient kept having intermittent episodes of the arthralgia in the same joints, lym- phadenopathy and erythematous macules on her arms, abdomen and legs. The results of the laboratory tests in the first office visit were as follows: hemoglobin, 11.9 g/dL; leukocytes, 6700/mm 3 Abbreviations: RV, rubella virus; vRV, vaccinal rubella virus; PBMCs, peripheral blood mononuclear cells; SIRCs, rabbit corneal epithelium cells; CPE, cytophatic effect; PCR, polymerase chain reaction; RT, reverse transcription; NSAIDs, nons- teroidal anti-inflammatory drugs. ∗ Corresponding author at: Faculdade de Medicina da Universidade de São Paulo, Departamento de Moléstias Infecciosas e Parasitárias Av. Dr. Enéas de Carvalho Aguiar, 470, São Paulo, SP 05403-000, Brazil. Tel.: +55 11 97653 0825; fax: +55 11 3666 4600. E-mail addresses: felipegualberto@gmail.com, felipegualberto@yahoo.com.br (F.A.S. Gualberto). (67S/21L/3E/7M%); platelets, 314,000/mm 3 ; erythrocyte sedimen- tation rate 51 mm. Liver and renal studies were normal, as well as serum electrolytes. Antinuclear antibody titer was 1/160 (nuclear homogeneous pattern) and anti-rheumatoid factor was negative. Autoantibodies to DNA, Sm, RNP, Ro, La, histone, lupus anticoagu- lant, cardiolipin and others markers of autoimmune diseases were all repeatedly negative. The patient underwent investigations for primary humoral and cellular immunodeficiencies, including T, B and NK cells immunophenotyping and lymphocyte proliferative responses to T and B cell mitogens and some antigens, which were all normal. Serum complement levels were normal. During the time she was followed in the ambulatory, the exams results remained similar to the ones initially collected. Blood cultures for bacterial and fungal infections were negative. Investigation for other dis- eases included serology for cytomegalovirus, herpes simplex 1/2, human parvovirus B19, mumps, Epstein–Barr virus, hepatitis A and Toxoplasmosis. All of them were IgM negative and IgG positive. Serology for Dengue and Herpesvirus type 6 was negative (IgG and IgM). Syphilis, HIV and hepatitis C serology was negative. Anti- HBsAg > 10 UI/mL and other markers for hepatitis B were negative. Enzyme immunoassay (Siemens, Marburg, Germany) was used to determine IgG/IgM against rubella virus (RV) and measles. IgM was negative and IgG positive for both. Rubella IgG avidity was deter- mined using enzyme immunoassay Dieese Enzywell (Diagnostica Senese, Italy). IgG antibodies were positive with high titers in serum specimens and found to contain high rubella-specific IgG avidity (AI: 60–89%). What other tests would you perform? What is the possible cause behind the clinical manifestations? 1386-6532/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jcv.2012.07.017