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recognizing childhood diseases, part 1

By | April 27, 2010

did you know that doctors often have dreams about patients? maybe not specific patients. but it’s natural to dream about your work – even to have bad dreams.

i dreamed that i had a patient, a little toddler, who suddenly became terribly terribly ill, with an all-over red rash, a high sweaty fever, delirium (with staring, scary eyes), gasping for breath. i sent the family straight to the emergency room, where the toddler was admitted to the intensive care unit and put on a ventilator – at death’s door. the family was bewildered and very angry. they told the hospital workers that of course they knew that if they didn’t vaccinate their child, their child could get a childhood disease – but “nobody ever told them” that it could mean their child could get that sick. and the hospital workers were all hating on me directly, because i was the family doctor that did not vaccinate this child.

i think i had this dream because i went to bed thinking about the toxic fungus that is raising alarms in oregon. i went to bed wondering if i’d recognize it – i don’t ordinarily order up a lung biopsy when somebody has a cough!

the dream made the wonder – not for the first time – if i’d recognize, for example, diphtheria.

would you? if your child got the measles or mumps, would you be able to recognize it? what if the illness went from simply “terribly ill, can’t sleep, fretting and fusssing, throwing up,” etc, to empyema or encephalitis? how would you know if your grade-schooler was developing liver cirrhosis from chronic hepatitis? what are the warning signs of tetanus? of polio?

doctors who went to medical school in the last couple decades simply do not see these cases – unless we are lucky enough to take a field trip to a faraway land that doesn’t have a modern public-health infrastructure – a place like haiti – or afghanistan – or germany (?) – or british columbia (?!) – or minnesota (??!!!). or, you know, ashland.

let’s talk, not about shots, but about “childhood diseases.”

HiB and Pneumococcus:
HiB is named “hemophilus influenzae B,” but it’s not a flu virus, it’s a bacterium. the Pneumococcus is named “streptococcus pneumoniae,” but it is not the same kind of strep as the one causing strep throat (or the GBS that we test pregnant ladies for). if you live in a community where less than about 85% of the population is not fully vaccinated against them, then your unvaccinated child will not have the benefits of “herd immunity” and is likely to be exposed to them. how the disease affects your kids will depend on a lot of other factors (age, genetics, nutrition, stressors, virulence of the bacterial strain, etc.).

Pneumococcus and HiB are both respiratory diseases spread by airborne droplets – highly contagious. they don’t have an instantly-recognizable sign (like chickenpox does), but instead cause your basic bad cold and/or ear infection (often coming on after an upper respiratory virus) – if they are uncomplicated.

these germs have a high frequency of complications. these include pneumonia, empyema, pericarditis, meningitis, epiglottitis, mastoiditis, orbital cellulitis, and septic arthritis. kids with these are usually admitted to the hospital and sometimes need surgery and/or life support.

so let’s review these complications.

signs of pneumonia (lung infection): fever, cough, fast breathing. respiratory distress danger signs: in a baby, look for retractions and flaring (muscles around the ribs sucking in and nostrils opening wide when the baby struggles to get a breath). children will often try to stay still, to concentrate on breathing. pneumonia can usually be heard with a stethoscope (decreased breath sounds over a lobe and/or wet crackles) and shows up on x-ray. if a pneumonia is very bad, the baby or child might need to be admitted to the hospital and given IV antibiotics and other medications.

signs of empyema (lung abscess): same as pneumonia, and usually develops from pneumonia. fluid and pus from the pneumonia collect in the membranes that normally surround the lungs, and form a jelly that stops the lung from expanding. it hurts when they breathe in, and a child might breathe shallowly, holding their ribs, or lie down on the affected side to “splint” it (keep that lung from moving and hurting). fever and other pneumonia symptoms continue despite taking antibiotics. the child simply does not get better, and often starts to lose weight and stop growing. they need to be hospitalized and have the jellied abscess removed surgically. note: pericarditis, or heart inflammation, has similar symptoms. the child might need to have pus drained from the sac around the heart.

signs of bacterial meningitis (infection of the membranes surrounding the brain and spinal cord – a medical emergency): can start in two different ways: gradually, after a feverish illness, or suddenly, with life-threatening illness. because meningitis is a disease of the nervous system, many of the symptoms reflect this: headache, worse head pain when lights are bright, confusion, unresponsiveness or restlessness, seizures. nausea and vomiting, not eating or drinking, and fever or abnormally low temperature can also occur. a baby may have a bulging soft spot (on top of their head), or, if dehydrated, a sunken soft spot. some kids get a very stiff neck, and can’t bend their head so their chin goes to their chest. kids with symptoms like these are usually “pancultured”: the blood and urine are cultured, they get a chest x-ray and a head CT, and they need to have a spinal tap, to be sure of the diagnosis and guide treatment. they would be hospitalized with IV antibiotics and other medications. if not treated, this disease is usually fatal.

signs of epiglottitis (throat/epiglottis infection – a medical emergency, usually caused by HiB when not vaccinated): the epiglottis is the muscle that closes off your airway when you swallow. if it gets infected and swells up, you can’t breathe. kids with this infection usually have a high fever and appear very sick. they struggle to breathe and lean forward, drooling (can’t swallow). if they can speak, they have a characteristic muffled “hot potato” voice – like someone trying to talk with a piece of hot potato in their mouth. their breathing is horse and noisy. they need to go to the emergency room immediately, to have an artificial airway placed (a breathing tube or tracheostomy) until antibiotics clear the infection.

signs of mastoiditis (infection of the skull bone): this is usually a complication of bacterial ear infections (usually pneumococcus and HiB, when not vaccinated). the baby or child has a current or recent ear infection, and the area around the affected ear is swollen, red, and very tender; sometimes the ear canal is narrowed by swelling, and the ear sticks out on that side. the child might have a fever. if not treated quickly, it can turn into a brain or bone abscess, meningitis, facial paralysis, or deafness. the baby or child would need to be in the hospital, with spinal taps, CTs, blood cultures, antibiotics, and possibly surgery.

signs of orbital cellulitis and periorbital cellulitis (eye infection): these are usually complications of bacterial sinus infections (usually pneumococcus and HiB, when not vaccinated). they appear as a sudden red-hot swelling of the skin around the eye and the eyelid, and are very painful. may or may not cause a fever. orbital cellulitis (infection in the eye socket itself) is a danger to the brain (abscess, meningitis) and the vision. peri-orbital cellulitis is an infection that is just in the skin around the eye, not in the eye socket itself, and is less dangerous (though the infection can spread to the orbit). how to tell them apart? orbital cellulitis causes swelling that makes it hard to move the eye, causing double vision. however, this can be hard to observe when the eye is swollen shut. the baby or child will need a head CT or MRI as well as the usual tests for blood infection and meningitis.

signs of septic arthritis (joint infection): usually appears after a feverish upper respiratory infection (especially HiB); basically, the bacterial infection spreads to the joint. usually affects hips, knees, ankles. the fever continues (sometimes with “picket-fence” spikes and drops), the baby or child appears very sick, the affected joint swells, and the child can’t move it due to pain (“pseudoparalysis”). the child will need a joint tap (fluid taken out of the joint with a needle, often under anesthesia) in addition to blood tests, to guide the choice of antibiotic. if untreated, the infection can spread throughout the body; also, the joint itself may be damaged and not grow correctly. this is a particular problem when it’s the hip that is infected.

when kids develop complications of HiB and Pneumococcus, like these above, other kids in close contact (if unvaccinated or partly vaccinated) usually need to be treated, too, due to how contagious and virulent these diseases are. adults who are immunocompromised (for example, diabetic, on chemotherapy, or taking steroids) need to be treated too, if they are in close contact.

can i tell you your child’s risk of getting sick, or getting a complication, from these diseases? no – because it depends on so many factors (age, genetics, nutrition, stressors, virulence, etc.). i can tell you that if your child has perfect health and a perfect immune system and encounters a very imperfect strain, then the risks are practically nil. odds of this? also practically nil.

we can look at the histories of these diseases, which are as old as the hills, and see that the Pneumococcus and HiB have been a major source of heartbreak through many generations – but the conditions that pertained to those stories are likely very different from your individual child’s/family’s condition. so it’s just hard to say. i can confidently predict that, as “herd immunity” deteriorates, we’ll unfortunately develop a brand-new set of stories – the stuff of bad dreams for doctors, if not for everybody else.

stay tuned for part 2 – childhood diseases that have more distinctive signs (like measles and mumps), even when they don’t cause these particular complications.

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