GPAtlas🧭 When to suspect
Suspect rubella (German measles) in an incompletely immunised person with a mild illness: a pink, discrete maculopapular rash that begins on the face and spreads down to the trunk and limbs, fading by about day 3. It is typically accompanied by tender lymphadenopathy – classically post-auricular, sub-occipital and posterior cervical – with at most a low-grade fever. Up to half of infections are subclinical, and adults (especially women) often have arthralgia.
Rubella is now rare in the UK because of the MMR (measles, mumps and rubella) programme, and the rash is non-specific – it cannot be told apart clinically from parvovirus B19 and several other viral rashes. Two things therefore matter far more than the rash itself: rubella is a notifiable disease, so notify the health protection team (HPT) on clinical suspicion without waiting for results; and the entire clinical significance lies in pregnancy, where infection can cause congenital rubella syndrome (CRS).
Raise suspicion particularly in those who are unvaccinated or partially vaccinated, born or raised outside the UK, or with recent travel to areas where rubella still circulates – most UK rubella in pregnancy is now acquired abroad or in unimmunised women. In every case, the first question to settle is: is the patient, or any of their contacts, pregnant?
| Looks like rubella, but consider | Distinguishing features |
|---|---|
| Measles | More unwell; prodromal cough, coryza and conjunctivitis (the “3 Cs”); Koplik spots; confluent rash spreading from behind the ears; high fever. |
| Parvovirus B19 (slapped cheek) | Bright “slapped-cheek” facial erythema then a lacy rash on the limbs; clinically indistinguishable in pregnancy – always co-test for both. |
| Scarlet fever | Sandpaper rash sparing the face, sore throat, strawberry tongue and perioral pallor; responds to antibiotics. |
| Roseola / enterovirus / drug rash | Roseola: high fever then rash as the fever settles. Always consider a drug eruption from the history. |
Source: UKHSA · Green Book (Rubella)
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