Bone changes after rubella vaccination.

Abstract

A 1 0-year-old girl received rubella (German measles) and measles (rubeola) vaccines; 1 week later, she developed vague lower-extremity pain that persisted for about 7 days. This was followed by high temperatures, bilateral thigh pain, and a macular rash over the anterior trunk, which lasted for 3 days. She was treated with penicillin V although the antistreptolysin 0 and streptozyme titers were negative. She defervesced and was well for several days. Then swelling, tenderness, increased warmth, and intermittent erythema developed over the medial malleoli. The increased warmth and erythema gradually subsided. Because the pain and tenderness persisted, she was referred to the University of Wisconsin Clinical Health Science Center 8 months after vaccination. On physical examination, there was mild soft-tissue swelling over the medial malleoli and tenderness to deep palpation. Range of motion of the joints was normal. Pertinent laboratory data showed a sedimentation rate of 38; white blood cell count of 5600/mm3 with normal differential; rubella hemaglutination titer of 1 :32; 1gM specific rubella antibody titer of <1 :4; measles hemaglutination titer of 1 :8; negative bone-marrow cultures for bacteria, viruses, and fungi; positive HLAB27; normal C3 and C4; negative rheumatoid factor; negative anti singleand double-stranded DNA; and negative ANA. Ankle films demonstrated soft-tissue swelling, sclerotic and lytic areas in the tibial metaphyses extending to the growth plate, and periosteal reaction along the medial metadiaphyses of the tibiae; the findings were more pronounced on the right (figs. 1A and 1B). On a subsequent skeletal survey, there were small lytic areas with sclerotic borders in the distal right radial and ulnar metaphyses (fig. 1 C). Otherwise, the survey was normal. The child was followed clinically without treatment because the findings were thought most likely to be secondary to the rubella vaccine. Two months later, not only had there been clinical improvement but also resolution of the periosteal reaction and slight healing of the metaphyses. Progressive healing was noted on ankle films at 1 year and at 17 months after vaccination. Dunng this time, the patient had occasional clinical symptoms and the sedimentation rate remained elevated. Two years later, the patient had become asymptomatic and remained so for another 2 years, at which time she was again seen because of left ankle pain, swelling, and erythema. The sedimentation rate was 38. Aadiographs of the right wrist demonstrated a small lucency with surrounding sclerosis in the medial metaphysis of the radius. The metaphyses of the tibiae were normal. However, there was soft-tissue swelling about the left ankle and slight cortical irregularity of the medial malleolus. A radionuclide scan limited to the lower legs, ankles, and feet revealed increased blood flow about the medial left ankle and tarsals and a similar distribution of increased bone activity. An open biopsy of the medial left ankle demonstrated pannus formation, collagenous degeneration, and erosions. Cultures of the biopsy site were negative for bacteria, viruses, and fungi. Subsequently, the patient has carried the diagnosis of pauciarticular juvenile rheumatoid arthritis and becomes symptomatic when taken offaspirin.