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A case of reinfection with the wild rubella virus in the 8th gestational week is reported. The patient had preexisting hemagglutination inhibition antibodies of low titer following immunization with rubella vaccine. Reinfection was accompanied by clinical symptoms and the presence of rubella-specific immunoglobulin M (IgM) of high titer. Following termination of pregnancy no rubella virus could be isolated from the fetal tissues and the fetal blood contained no specific IgM antibodies. These results should encourage the use of cordocentesis before decision on interruption of pregnancy. Dr. Mati Zolti, Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer 52621 (Israel) Introduction Rubella reinfection during pregnancy is generally not considered teratogenic [1]. It is not clear, however, whether reinfection accompanied by clinical symptoms and the appearance of specific immunoglobulin M (IgM) antibodies can affect the fetus [2]. We present a case of reinfection at 8 weeks’ gestation with clinical signs and a high titer of specific IgM. Pathological examination of the aborted fetus at 14 weeks’ gestation revealed no signs of infection with the rubella virus. Case Report The patient was a 27-year-old woman, who had received two rubella vaccinations, the ñrst at the age of 12 years and the second 13 years later, after she was found to be rubella-seronegative. No subsequent serological tests were performed until she was 6 weeks pregnant and her 11-monthold child developed a rash which was suspected to be rubella. Tests of maternal blood samples showed low-titer immunoglobulin G (IgG) antibodies, but were negative for specific rubella IgM (table 1). Two weeks later she developed a fever (38 °C) and general malaise, but no skin rash. Subsequent blood samples showed a significant rise of IgG antibodies and a high titer of specific IgM. Serological examination of the 11-month-old son confirmed recent rubella infection. Maternal serological tests for other vimses excluded recent cytomegalovirus or Epstein-Barr vims infection. The test for rheumatoid factor was negative. D ow nl oa de d by : 54.70.40.11-11/2/20176:09:53PM The combination of clinical symptoms and high rubella-specific IgM led to the decision toterminate this pregnancy in the 14th week by intra-amniotic injection of prostaglandin F2αThefetal blood obtained from the heart following expulsion was positive for rubella IgG, but had noIgM antibodies. The fetal tissues and placenta showed no rubella vims, when tested by theinterference method in monkey kidney cell cultures [3].DiscussionThis case illustrates one of several new diagnostic problems which arise following massimmunization with rubella vaccine. It is well known that the available rubella vaccines licensedso far immunize only about 95% of seronegative subjects [4].Our patient apparently failed to seroconvert following her first vaccination. The secondimmunization induced a low antibody response. Following infection of her 11-month-old childwith wild rubella virus, she experienced reinfection, accompanied by clinical symptoms. Thisclinical event resulted also in the appearance of rubella-specific IgM, which, in contrast tosimilar cases reported by others, was of high titer [5]. Since the tests for cytomegalovirus,Epstein-Barr virus, IgM and rheumatoid factor were negative, the decision on termination ofpregnancy seemed justified.Rubella IgM185Table 1. Results of antibody tests in serial blood samplesSampleDate Rubella tests’ Tests for other factorsNo.HI IgM neutralization RF EBV CMV1 3.4.1988 16–32 Neg 8 NT 10 8014.4.1988 64 Neg NT NT NT NT22.4.1988 2,048 +++ > 128 NT NT NT29.4.1988 2,048 +++ NT Neg 10 805 3.5.1988 2,048 +++ 5*128 NT NT NT6 18.5.1988 2,048 ++ > 128 NT NT NTChild 1.5.1988 256+++ NT NT NT NTFetus2 18.5.1988 128 Neg NT NTNT NTSample No. 1–6 represent maternal blood. HI = Hemagglutination inhibition; RF = rheumatoidfactor; EBV = Epstein-Barr virus; CMV = cytomegalovirus; Neg = negative; NT = not tested.1 Reciprocal of titer.2 Day of pregnancy termination.Tests on the aborted fetus, however, suggested that this decision was premature. No virus wasisolated from either the placenta or fetal tissues, although infection at this early gestational age isusually accompanied by a high isolation rate from fetal tissues [6]. The recent introduction ofpercutaneous umbilical blood sampling (cordocentesis) [7, 8] seems to offer a better diagnosticapproach to rubella infection in pregnancy. In our case the fetal blood sampling was performedtoo early to be significant. The test for specific IgM in the cord blood at 22 gestational weekswould have provided important information and probably have spared an unnecessarytermination of pregnancy.ReferencesCradock-Watson JE, Ridehalgh MKS, Anderson MJ, Pattison JR: Outcome of asymptomaticinfection with rubella virus during pregnancy. J Hyg Cambridge 1981;87:147–154. Downloadedby: 54.70.40.11-11/2/20176:09:53PM Miller CL, Miller E, Waight PA: Rubella susceptibility and the continuing risk of infection inpregnancy. Br Med J 1987,294: 1277–1278. Parkman PD, Buescher EL, Artenstein MS: Recovery of rubella virus from army recruits. ProcSoc Exp Biol Med 1962;Ill:225– 230.Plotkin SA, Farquar JD, Ogra PL: Immunologic properties of RA-27/3 rubella virus vaccine. Acomparison with strains presently licensed in the United States. JAMA 1973;225:585–590.Morgan-Capner P, Hambling MH, Coleman TJ, et al: Detection of rubella-specific IgM insubclinical rubella reinfection in pregnancy. Lancet 1985;i:244–246.Cradock-Watson JE, Miller E, Ridehalgh MKS, Ho-Terry L: Detection of rubella virus in fetaland placental tissues and in the throats of neonates after serologically confirmed rubella inpregnancy. Prenat Diagn 1989;9:91–96.Daffos F, Forestier F, Grangeot-Keros L, et al: Prenatal diagnosis of congenital rubella. Lancet1984;ii. 1–3.Morgan-Capner P, Rodeck CH, Nicolaides K, Cradock-Watson JE: Prenatal diagnosis of rubella.Lancet 1984;ii:343. Downloadedby: 54.70.40.11-11/2/20176:09:53PM