Rubella virus in association with congenital cataract at makkah eye complex

Muhennad H Halees; Mahgoub Saleem; Arwa Abdalla

doi:10.4103/bijo.bijo_12_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 7 | Issue : 1 | Page : 16-20

Rubella virus in association with congenital cataract at makkah eye complex

Muhennad H Halees¹, Mahgoub Saleem², Arwa Abdalla³
¹ Shami Eye Center, Al Neelain University, Khartoum, Sudan
² Department of Ophthalmology, Faculty of Medicine, Al Neelain University, Khartoum, Sudan
³ Department of Pediatric Ophthalmology, Makkah Eye Complex, Khartoum, Sudan

Date of Submission	06-Jul-2020
Date of Acceptance	10-Jul-2020
Date of Web Publication	31-Dec-2020

Correspondence Address:
Prof. Mahgoub Saleem
Department of Ophthalmology, Faculty of Medicine, Al Neelain University, Khartoum 11111, P.O. Box 10139
Sudan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/bijo.bijo_12_20

Abstract

Background: Rubella is a viral disease that causes many systemic and ocular postnatal anomalies known as congenital rubella syndrome (CRS). The most common ocular disorder is congenital cataract.
Purpose: The purpose of this study was to determine the prevalence of CRS and its association with congenital cataract and systemic comorbidities.
Materials and Methods: In this cross-sectional, hospital-based study, full ophthalmic and systemic examination was carried out on 45 infants (n = 45), aged below 1 year, with congenital cataract, attending the Pediatric Ophthalmology Clinic at Makkah Eye Complex, Khartoum, Sudan, in the period between February 2015 and June 2016. The 45 children were booked for phacoemulsification plus intraocular lens implantation. The children's biodata and maternal and neonatal history were obtained from the mothers and plotted in case investigation forms. Venous blood sample and lens aspirate were studied for rubella IgM, IgG, and polymerase chain reaction beside rubella virus detection in the National Laboratory of Measles and Rubella.
Results: Blood and lens aspirate was collected from the study infants, which revealed that 38 infants (84%) were negative for rubella, whereas only seven infants (16%) showed positive result. The majority of the rubella-positive patients (n = 5, 71%) had bilateral cataract and only two infants had unilateral cataracts. Only one rubella-positive case (14.3%) had microphthalmia in one eye. Unfortunately, screening for pigmentary retinopathy was not done postoperatively. Four (57%) out of the seven rubella-positive cases reported systemic CRS. Microcephaly, patent ductus arteriosus, ventricular septal defect, and pulmonary hypertension were reported in one case (14.3%) each. Three mothers (43%) from the rubella-positive group had a history of febrile illness during pregnancy.
Conclusion: Congenital cataract and systemic comorbidities are common in infants with congenital rubella.

Keywords: Congenital cataract, congenital rubella syndrome, glaucoma, IgG, IgM, pigmentary retinopathy, polymerase chain reaction

How to cite this article:
Halees MH, Saleem M, Abdalla A. Rubella virus in association with congenital cataract at makkah eye complex. Albasar Int J Ophthalmol 2020;7:16-20

How to cite this URL:
Halees MH, Saleem M, Abdalla A. Rubella virus in association with congenital cataract at makkah eye complex. Albasar Int J Ophthalmol [serial online] 2020 [cited 2023 Mar 31];7:16-20. Available from: https://www.bijojournal.org/text.asp?2020/7/1/16/305760

Introduction

Rubella, commonly known as German measles,^[1] is one of the important viral infectious diseases worldwide, which is responsible for not less than 100,000 cases of congenital rubella syndrome (CRS) every year.^[1] It is caused by the rubella virus which is a pleomorphic RNA virus in the Togaviridae family of the genus Rubivirus. Usually, it is a very mild infection but still can have some devastating effects in the infected newborn infants. It is responsible of what is called CRS. It is defined as a viral disease that affects newborn infants whose mothers are infected by the rubella virus^[2] during their early pregnancy, 1^st trimester of the pregnancy or the first 3 months of pregnancy. It is unlikely to affect the babies after the 4^th month of pregnancy.^[3],[4],[5]

Although CRS has been reduced by the adoption of “rubella-containing vaccines,”^[6],[7] still some cases are being seen in some developed and developing countries, and Sudan is not an exception. It continues to be endemic^[2] in many parts of the world.^[8],[9] CRS causes intrauterine infantile growth retardation, resulting in many systemic and ocular pathologies. It involves multiple organ systems and has a long period of active infection and virus shedding in the postnatal period. The resultant postnatal anomalies include cataracts, nerve deafness, cardiac anomalies, and mental retardation, with late complications including diabetes, thyroid disease, growth hormone deficiency, and progressive panencephalitis.^[1],[10] It involves multiple organ systems and has a long period of active infection and virus shedding in the postnatal period.

Ocular diseases are the most common rubella disorders (78%) in CRS followed by hearing defects (66%), cardiac disorders (58%), and mental retardation (42%).^[11] Blindness due to congenital cataract (15%), unilateral or bilateral pigmentary retinopathy (25%-50%), and congenital glaucoma (10%) beside deafness are the more profound CRS disorders.^[12] CRS typically causes a Scarletiniform rash which usually starts on the face and spreads to the rest of the body. It begins around 2 weeks after exposure and lasts for 3 days, followed by cervical lymphadenopathy,^[2],[13] and mild constitutional symptoms in around 2 weeks later after exposure and for the last 3 days. A fever, sore throat, and fatigue may also occur.^[10],[13]

Materials and Methods

In this cross-sectional, hospital-based study, full ophthalmic and systemic examination was conducted on 45 infants (n = 45), aged below 1 year, with congenital cataract, attending the Pediatric Ophthalmology Clinic at Makkah Eye Complex (MEC), Khartoum, Sudan, in the period between February 2015 and June 2016. MEC, as part of Al Basar International Foundation, Al-Riyadh, Khartoum, Sudan, is a big tertiary eye care center which was launched in September 2003, as a high-volume, highly qualified ophthalmic institution in Sudan and in the surrounding area.

All these 45 children included for this study were aged below 1 year, and they were planned for phacoemulsification plus intraocular lens implantation (IOL). Their biodata and maternal and neonatal history were taken from the mothers and plotted in case investigation forms. Venous blood sample and lens aspirate were studied for rubella IgM, IgG, and polymerase chain reaction (PCR) beside rubella virus detection in the National Laboratory of Measles and Rubella. The whole-needed data were collected in a “case investigation form,” which contains infant and maternal background and medical and obstetrical history. Samples collection and laboratory testing and confirmation were done and followed by the researchers.

Sample collection

Collection of venous blood sample was done by collecting 1 mL of the whole blood by venipuncture in “Tiger-Top Vacutainers” (serum separator tube) (Becton, Dickinson and Company, BD Medical, Diagnostics Preanalytical Systems; 1 Becton Drive, Franklin Lakes, NJ, USA 07417-1880, 201.847.6800; www.bd.com/vacutainer). The blood was allowed to coagulate in the tube undisturbed in a rack for 2 h at room temperature, or until complete retraction of the clot from the serum. The Tiger-Top tube is centrifuged at 1000 ×g for 10 min. The serum was transferred to a separate labeled sterile tube. The sample was transported to a plastic Cryo-Vial^® and stored cold at 70°C in a freezer and shipped on dry ice.

Collection of lens aspirate from cataract removal surgery is collected in a syringe attached to a vitreous cutter in the phacoemulsification machine at the beginning of the surgery and immediately transported to the laboratory. The lens aspirate was transferred to a leak-proof tube containing at least 1 ml. The lens aspirate was stored cold at 70°C in the freezer and shipped on dry ice to the National Bank in Khartoum.

Laboratory testing and confirmation

The collected serum samples from the rubella cases were tested for Immunoglobulin M (IgM), Immunoglobulin G (IgG) and the Polymerase Chain Reaction (PCR) in the “Measles and Rubella” National Laboratories of the Ministry of Health (MOH). In the meantime, the rubella virus was detection from the lens aspirates.

Data were statistically analyzed using the Statistical Package for the Social Sciences (SPSS for Windows, version 20; IBM SPSS Inc. PASW Statistics for Windows, Version 20.0; 2009. Chicago, IL, USA)

Ethical clearance was obtained from Al Basar Institutional Review Board at Makkah Research Center of MEC. Written and verbal consents for the surgery and the study extract were obtained from the parents after full explanation of the study objectives and procedures; confidentiality and anonymity of each infant and family identity were adhered.

Results

In total, 45 Sudanese infants aged below 1 year with congenital cataract undergoing therapeutic phacoemulsification plus IOL implantation at MEC from February 2015 to May 2016 were involved in this study. The blood and lens aspirate which were collected from the study infants revealed that 38 infants (84%) were negative for rubella, while only 7 infants (16%) showed positive result [Table 1] and [Figure 1]. Most of the rubella-positive patients (n = 5, 71%) had bilateral cataract and only two infants had unilateral cataracts [Figure 2].

Table 1: Prevalence of rubella in congenital cataract

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Figure 1: Prevalence of rubella in congenital cataract. Note: CRS – Congenital rubella syndrome, CC – Congenital cataract

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Figure 2: Bilateral cataract versus unilateral cataract in rubella-positive group

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Only one patient (14.3%) of the rubella-positive cases reported microphthalmia in one eye[Table 2]. Unfortunately, screening for pigmentary retinopathy was not done postoperatively. Four (57%) out of the seven rubella-positive cases reported systemic CRS.

Table 2: Associated ocular manifestations(Microphthalmia)

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Unilateral microphthalmia, microcephaly, patent ductus arteriosus (PDA), ventricular septal defect (VSD), and pulmonary hypertension were reported in one case (14.3%) each [Figure 3]. Three mothers (43%) from the rubella-positive group had a history of febrile illness during pregnancy [Table 3].

Figure 3: Systemic comorbidities of congenital rubella syndrome congenital cataract. Note: MC – Microcephaly, PDA – Patent ductus arteriosus, VSD – Ventricular septal defect, PH – Pulmonary hypertension, CRS – Congenital rubella syndrome.

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Table 3: Antenatal history of febrile illness

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Discussion

Rubella (a Latin term meaning “little red”) is generally a benign communicable exanthematous disease caused by rubella virus. Half of the cases can pass asymptomatic.^[14] The virus can be transmitted to the fetus through the placenta during early pregnancy?^[15] and causes serious ocular and systemic congenital defects. These days, CRS is rarely seen because of the successful national and international immunization programs?.^[16],[17]

Delayed manifestation of CRS underscores the importance of careful follow-up of these patients because the altered immune system of CRS patients allows complications to take place later in life?.^[18]

Five percent of nontraumatic bilateral cataracts among infants are due to rubella unless proved otherwise.^[19] Congenital cataract in newborns aged <1 year has a high sensitivity for detecting CRS in India. It is the only clinical eye finding that has enough high sensitivity and specificity to be useful as a screening tool for CRS?.^[20]

There are very few studies in literature that assess the prevalence of CRS in the general population. Dewan and Gupta in their Indian study gave a vague rate with a wide range of 1%–15% laboratory evidence of CRS?.^[7]

In the current study, only 15.5% (16%) of the infants with congenital cataract were positive to rubella infection with laboratory evidence, a result which was in line with the results of Dewan and Gupta (India, 2012).^[7]

Lambert [21] in his review quoted the results of Vijayalakshmi et al.: of Aravind Eye Hospital in Madurai, India (2007),[20] stated that: “among congenital cataract children screened for CRS, nearly 2% had ocular signs suggestive of CRS. While 27% of them may developed ocular signs of CRS later in their life; at elder ages.” A situation which was not checked in the current study, where children below 1 year age were examined once at the time of presentation and surgery. Hence, it can be observed that the age group of the affected children is similar both in the present study and that of studies in literature , below 1 year, which alerts early awareness of infant leukocoria among the public, especially in bilateral CRS congenital cataracts.

The current study showed that all the rubella-positive infants had cataract (100%), in contrary to two Indian studies of two decades apart, by Vijayalakahmi et al. (India, 2002) and Murhekar et al. (India, 2020), who reported 67.5% and 60% of CRS cataract, respectively?.^[22],[23] Meanwhile, 71% of our infants had bilateral cataract and 29% had unilateral cataract, while the same Indian data by Vijayalakahmi et al. reported higher percentage of cataract bilaterality (89%) and low incidence of unilateral cataracts (11%). One case of unilateral minimal degree of microphthalmia was seen (14.3%) compared with the high rate of Vijayalakahmi et al. (India, 2002) (85.5%) in microphthalmia cases.

In the current study, systemic rubella disorders such as congenital heart disease (CHD) constituted 28.6% which included 14.3% as PDA, in contrary to that of studies by Schluter et al. (USA, 1998)^[24] and Sriwahyuni et al. (Indonesia, 2020)?.^[25] The former reported 71% of CHD, with 72% of them as PDA, and the latter reported 77% of CHD. Other studies even reported higher rate of up to 80% CHD by Murhekar et al. (India, 2020)?.^[23]

This discrepancy in the above results also appeared in CRS CHD (75%) and other systemic disorders,^[22],[24] which could be due to sample sizes and age differences.

Nearly 43% of the mothers of the rubella-positive group in the current work had a history of febrile illness during pregnancy, in contrary of 14.3% in Satti et al.'s Sudanese CRS study^[26] and 15.5% in Murhekar et al.'s Indian CRS study.^[23] There is no clear explanation of such discrepancies as all the study areas are endemic to different types of fever or “pyrexia of unknown origin” such as malaria, typhoid, and other nonrubella viral infection, which can be mixed, to some extent, with mild attack of rubella viral infection.

The current four (57%) out of the seven rubella-positive cases reported systemic multisystem CRS, whereas one infant reported an associated microcephaly, one infant had nonsignificant PDA, one infant had VSD, and one infant had pulmonary hypertension, 14.3% each. This wide spectrum of the multisystem CRS was far less than that of the study by Vijayalakshmi et al.,^[22] who reported a wide spectrum of ocular and systemic disorders involving multisystems with a rate of 70%. Microcephaly, PDA, VSD, and pulmonary hypertension were reported in one case (14.3%) each. Three mothers (43%) from the rubella-positive group had a history of febrile illness during pregnancy.

The limitation of the current study was the failure of screening pigmentary retinopathy postoperatively, as pigmentary retinopathy (in form of salt and pepper) in Rubella is the most common retinal manifestation of CRS; its prevelance is almost 38% [ranged from 25% to 50%]).[22]

Conclusion

Ocular, ENT, and systemic comorbidities are common in infants presenting with congenital cataract associated with CRS. Therefore, infants with congenital cataract should be suspicious for CRS and subjected for full specialized medical ophthalmic review, such as CHD and pulmonary disorders. Large-scale rubella vaccination during the past decade has practically eliminated rubella and CRS in many developed and in some developing countries.

Recommendations

National large-scale rubella vaccination programs in infants and preschool age girls are strongly recommended as a preventive and control measure against CRS disease and its trend of comorbidities. The rates of CRS per live births should be serviced in the national maternity hospitals. The Ministry of Health and concerned authorities should work for national review or community-based studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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