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recognizing childhood diseases, part 2
By | April 29, 2010
although it seems morbid (or at least comorbid, ha ha – doctor joke), i feel a little jealous of the many doctors who tell stories of all the childhood diseases they saw during their training in the last century. although it was frightening and terrible to become a doctor during the polio epidemics, or to learn about rubella the hard way, in the nursery – at least they know how to recognize these phenomena! communities that don’t participate in vaccination programs must rely on word of mouth and decades-old accounts, to learn the natural history of these diseases.
even if you already have a handle on the readily-recognizable diseases discussed below (chickenpox, for example), it’s still wise to know how to recognize possible complications of childhood diseases – the reasons the vaccines were developed in the first place! – which could require hospital care.
we already discussed complications of HiB and Pneumococcus, which can be severe, even though in most cases these bacteria cause milder illness or are asymptomatic. these complications include:
pneumonia (lung infection),
empyema (lung abscess following pneumonia),
pericarditis (heart infection/abscess),
meningitis (brain and spinal-cord infection),
epiglottitis (throat/airway infection),
mastoiditis (skull bone infection following ear infection),
peri/orbital cellulitis (eye infection/abscess following sinus infection),
and septic arthritis (joint infection).
note that these complications can follow other childhood diseases as well (including diseases caused by bacteria and viruses we can’t vaccinate against anyway, like staph aureus or fifth disease).
now let’s discuss the childhood diseases that have well-known, characteristic signs and symptoms: diphtheria, pertussis, measles, mumps, rubella, and chickenpox.
diphtheria (“diff-THEERY-a”):
this is an upper respiratory bacterium that is spread by airborne droplets. it usually attacks the tonsils and throat, causing development of a “pseudomembrane” – a skin of grey gunk covering the tonsils that bleeds when scraped (e.g., during a throat culture); also can cause massive swelling of the neck. illness is caused by a toxin that the bacterium makes. the more pseudomembrane (it spreads from the throat down into the airways), the higher the toxicity.
here is a picture of the pseudomembrane:
complications: the toxin mainly affects the heart muscle (myocarditis); the heart rhythm can become irregular, and heart failure can occur.
the toxin also affects the nervous system, causing paralysis of the throat and facial muscles, and sometimes progressing to generalized paralysis days to weeks later.
again, the severity of these effects depend on how much toxin is present in the blood before treatment.
diphtheria is treated with antibiotics, to stop the bacteria from growing, and antitoxin, to stop complications. because vaccination (starting in the 1920s) has made diphtheria rare, the antitoxin is not commercially available in the US. the CDC has a diphtheria hotline for this reason.
the incubation period is about 3 days (takes 3 days to start getting sick after exposure). it’s contagious for 2-6 weeks from the start of illness, if untreated. antibiotics reduces contagion to 4 days.
close contacts need to be treated with antibiotics. the last major american outbreak was in the 1970s, in seattle. here’s a list of some countries your family members might visit, that have widespread and longstanding diphtheria problems: Egypt, Brazil, the Dominican Republic, Ecuador, Haiti, Afghanistan, China, India, Indonesia, Laos, Malaysia, Nepal, Pakistan, the Philippines, Thailand, Vietnam, Iran, Iraq, Saudi Arabia, Turkey, Russia, and countries of the former Soviet Union.
pertussis (also known as “whooping cough”):
this is an upper respiratory bacterium that is spread by airborne droplets. you should consider it in a child that has a cough for at least 2 weeks, if one of these is also true:
– the cough is paroxysmal (“pa-rox-IZZ-mal”), coming in uncontrollable coughing fits.
– the bursts of coughing are followed by a “whoop” – a gasp for air.
– the child vomits after and/or during coughing fits.
– one of the child’s close contacts has already been medically diagnosed with pertussis.
in babies, the classic whooping cough may be absent. sometimes babies simply stop breathing. in fact, this can be one cause of sudden infant death syndrome.
here is a video of a baby with pertussis:
in case you can’t play the video, click here for a .wav sound file of a typical cough in a 3-year-old.
the usual course is that pertussis incubates for about a week without symptoms, then causes an illness that is like a bad cold for a week or two (shorter in babies). after that, the cough gets worse and stays bad for 2-6 weeks. during recovery, the cough can continue to come and go for months. chest x-rays look pretty normal, unless pneumonia develops.
antibiotics may shorten the course and stop it from spreading throughout the community. kids need to stay home from school or daycare until they have gotten 5 days of antibiotics (or whatever the school’s rules say). close contacts (including someone they’ve spent an hour with, at arm’s length) should be treated within 3 weeks of exposure to the cough.
complications: pneumonia is number one (see previous post for symptoms). sleep deprivation is a real problem that makes it hard for kids to live and grow normally. some kids get mechanical complications of the severe cough, like incontinence (urine leakage/rectal prolapse), nosebleeds/red spots in the eyes, collapsed lung, broken rib, etc. some kids develop seizures. the complication rate is higher in babies.
a baby or child with complications may be hospitalized for supportive care, but the cough still lasts a long time. they will go home when they’re able to keep breathing, and able to eat and drink, despite the cough.
having pertussis once in the past does not prevent a person from getting it again. if you were vaccinated as a child but are now an adult, you also are able to get it again (the childhood shots don’t last a lifetime).
measles:
this is an upper respiratory virus that is spread by airborne droplets. (don’t forget, never give or take aspirin with a virus.) the incubation period lasts 10-14 days after exposure.
at first, when a baby or child gets sick, they feel terrible, eat poorly, and run a fever. after this, they usually get a typical triad of symptoms called “conjunctivitis, coryza, and cough,” which usually lasts about 3 days (but can last a week). this means red, swollen, itchy-sore eyes (inflammation of the eye conjunctiva), a very runny nose (coryza: “ko-REE-za”), and cough.
this part of the illness seems like the flu, so check the child’s mouth for “koplik (“COP-lick”) spots,” a kind of rash on the inner cheeks, toward the back. koplik spots are small red spots, some with a blue-white dot in the center. koplik spots appear about 48 hours before the skin rash.
the intense red measles rash starts on the face and washes down the body over the course of a week or so. the fever should go down after the rash appears. the rash “blanches,” meaning it will turn pale when you press on it – so you can distinguish it from bleeding into the skin, which does not blanch and is an emergency danger sign. (if you’re not sure, press on it firmly with a water glass you can see through.)
after the first few days, the rash fades to brown, then the outer layer of dead skin starts to flake away. here is a picture of a measles rash. note also the red eyes and runny nose:
there is no specific treatment; treat the symptoms, just as you would with the flu.
usually the child starts to feel better a couple of days after the rash appears. they may keep coughing for a couple of weeks.
the measles virus lowers a person’s resistance to other infections for several weeks (causes immunosuppression). they are more vulnerable to other viruses in particular, so continue to be very careful about hand-washing and don’t share towels or toothbrushes, etc.
if the fever persists after the 3rd day of rash, you should wonder if a complication is developing, and watch closely for the appearance of new symptoms.
complications: pneumonia is number one (see previous post for symptoms of pneumonia).
since measles is a virus infecting the whole body, complications can occur in various parts of the body, from eyes to the the heart sac and heart muscle, to the liver, and even the intestines (appendicitis).
late nervous system complications include post-infectious encephalomyelitis (a.k.a. ADEM, acute disseminated encephalomyelitis), and subacute sclerosing panencephalitis (SSPE).
post-infectious encephalomyelitis (“en-SEF-a-low my-a-LITE-us”): “encephalo-” means brain, and “myelo-” means spinal cord; “-itis” means inflammation. this inflammation of brain and spinal cord is caused by the body’s immune system reaction, not by measles virus itself. the nerves in the brain and spinal cord lose their myelin coating and don’t conduct signals normally, similar to multiple sclerosis. this seems to occurs in about 1 in 1000 cases of measles.
post-infectious encephalomyelitis starts during recovery, usually after the rash is gone. the symptoms include fever and symptoms of brain inflammation (headache, confusion, unresponsiveness or restlessness, falling or uncoordinated movements, seizures) and spinal-cord infection (neck or back pain and stiffness, paralysis, loss of bowel and bladder control).
the child needs blood tests, a spinal tap, and imaging to rule out any infection that could be treated with antibiotics (antibiotics can not help a viral infection.).
because this is an immune system reaction, the treatment is immune suppression with steroids or other medications. without treatment, there seems to be a 10-20% chance of death; with treatment, 5%.
after this illness, many kids have lasting problems with nervous system development.
SSPE: “subacute” means it drags on after the acute illness is gone; “sclerosing” (“skler-ROE-sing”) means scarring; “pan” means all-over; “encephalitis” means brain inflammation.
this is caused by measles infection that is never fully cleared by the immune system; a spinal tap shows an unusually high level of anti-measles antibodies.
symptoms appear 7-10 years after the acute measles infection, usually in people who had the measles when they were under two years old (a time of rapid nervous system development). the person develops personality changes, strange behaviors, and intellectual/school problems (usually before age 20). if diagnosed at this early stage, treatment with strong anti-viral medications can be tried.
the early stage is followed by progressive nervous system damage, with uncontrollable muscle jerks, limp paralysis, and death within 3 years.
these late complications are very rare!
after having measles once, a person is very unlikely to ever get it again.
a case of measles should be reported to the local public health department, either by you or your doctor.
mumps:
this is a virus (don’t forget, never give or take aspirin with a virus!) that is spread by airborne droplets, or by contact (sharing a glass or toothbrush, etc.).
the incubation period (without symptoms) lasts 14-18 days after exposure, but the person is contagious before symptoms appear, especially in the three days before swelling develops.
the infection starts with a low fever, loss of appetite, headache, and low energy. after about 2 days, “parotitis” (“pare-ott-EYE-tis”), meaning inflammation of the parotid (“pa-ROT-id”) glands – the big spit glands on the sides of the jawbone and neck – develops, usually on one side first.
the parotid glands make an enzyme called “amylase” (“AM-a-laze”) that breaks down starches when you eat food. a blood test showing higher levels of amylase in the blood will show that the swelling comes from the parotid glands, and not the lymph nodes or other parts. this can be helpful, because blood tests for the mumps virus can be negative even when the person clearly has the mumps.
the parotid swelling and tenderness lasts about 10 days. anything that makes one’s mouth water will cause parotid pain.
here is a picture of a child with the mumps:
there is no specific treatment; treat the symptoms, just as you would with the flu.
complications: can occur even when the parotid swelling is minor or absent. this can make mumps complications hard to diagnose.
the most frequent complication is meningitis (see previous post for symptoms of meningitis), which is usually mild, and usually goes away entirely, without permanent damage. it occurs more often in boys than girls, and about half of mumps meningitis cases occur without parotid swelling. the child needs a spinal tap to make sure it’s not a bacterial meningitis.
older (usually at least teenage) boys get testicle inflammation (a.k.a. orchitis, “ork-EYE-tiss”) about 40% of the time. the pain is severe, and the scrotum swells up and turns red-hot; about a third of the time it’s double-sided. double-sided inflammation can impair future fertility. older girls can get ovarian inflammation, which is similar in nature, but occurs only about 7% of the time.
children can also develop deafness as a consequence of mumps infection – usually one-sided and sudden, sometimes with dizziness and vomiting. without vaccination, this was the leading cause of one-sided deafness in kids.
in the US, there are about 250 cases of mumps even in a good year, usually in teenagers and young adults, because the vaccine is only about 85% effective. new york and new jersey are currently having an outbreak affecting nearly 2000 kids.
rubella:
this is a virus that is spread by airborne droplets. (don’t forget, never give or take aspirin with a virus.)
the illness that it causes is very mild, and a child or adult might not even know they have it.
it is important because if an unvaccinated pregnant woman catches it, it causes severe birth defects in her fetus, including deaf-blindness, brain problems, heart problems, and blood-cell abnormalities.
in the last major US epidemic in 1964, about 30,000 fetuses were affected. a widespread vaccination program started in 1989, and in 2005, the CDC announced that rubella had been wiped out in the US. however, unvaccinated pregnant women traveling to other countries, where it has not been wiped out, may be at risk.
it is routine in the US to do a blood test early in pregnancy to show whether the woman is already immune (from vaccination or from previous infection) or not. if a woman thinks she has been exposed to the disease, and doesn’t think she’s immune, she can get a series of blood tests to see if she is developing new antibodies to the virus.
rubella, when it has any symptoms, behaves like a mild form of measles, starting with head-cold-like symptoms (1-5 days) and progressing to a measles-like skin rash (3-5 days) which does not darken as measles do. adults get sicker than kids do. it causes arthritis – pain in the knees, wrists, and fingers – about a third of the time, starting when the rash appears and lasting for about a month.
there is no specific treatment; treat the symptoms, just as you would with the flu.
because of the implications for fetuses, it’s good to know how the contagion works during pregnancy.
rubella becomes infectious, with a high viral load, 7-10 days after first being exposed, and stays infectious for 2 weeks after the rash appears. it becomes less infectious after the rash starts (the viral load goes down as antibodies are made).
– if a non-immune mother is infected in the first trimester of pregnancy, rubella infects the fetus and causes defects 80-85% of the time, and miscarriage results from about 20% of infections. unfortunately, the kind of birth defects caused by rubella are very hard to see on ultrasound.
– if a non-immune mother is infected in the second trimester, the rate of fetal infection drops to around 25%. after 20 weeks, when the organs are fully developed, it is rare for the infection to cause any birth defects.
– if a non-immune mother is infected at 27-30 weeks in the third trimester, the rate of fetal infection is around 35%. the rate rises to nearly 100% around 36 weeks and beyond. again, it is rare for the infection to cause birth defects at this stage.
we don’t have any treatment for exposed fetuses.
about the shot: although women are advised to avoid pregnancy for a month after getting vaccinated, occasionally a woman accidentally gets a vaccine during early pregnancy. this has never been documented to cause birth defects the way the full-blown infection would.
it’s okay to get the shot while breastfeeding.
if you have had rubella once, you can catch it again, but your blood is full of antibodies that keep the viral load low, so you are unlikely to infect others. (unlikely does not mean impossible, unfortunately.)
varicella (chickenpox):
this is a virus that is spread by airborne droplets (espcially sneezes and coughs) and by direct contact with the blisters. (don’t forget, never give or take aspirin with a virus.)
varicella is a member of the herpes virus family (related to cytomegalovirus, epstein-barr virus, and herpes simplex virus which causes cold sores on the mouth and genitals).
all herpes viruses are very wimpy, and to protect themselves, they hide out in the nervous system (spinal cord), where the immune system is less vigilant. once you get a herpes virus, it lives in the nervous system forever, but only comes out and causes symptoms when the immune system is stressed (hence, for example, the name “cold sores” when you have a cold).
when the chickenpox herpes virus comes back out (“reactivates”), it is in the form of shingles, a blistery skin rash. having chickenpox once is no protection against the shingles (because the virus isn’t dead, just hiding).
incubation period: about 2 weeks. infection begins as fever, low energy, and loss of appetite (sometimes a sore throat). the rash usually starts 24 hours later and lasts 5-10 days.
the rash has a characteristic “dew on a rose petal” appearance, red spots with small blisters (pale or clear) that turn into scabs. it is itchy, so cut and file the child’s nails, and keep the child’s hands clean to prevent additional skin infection and scars. the rash will come and go in waves. here is a picture:
you can treat the rash with acetaminophen and ibuprofen (a.k.a. Tylenol and Motrin) for fever and discomfort, and with anti-itching measures, like oat-flour and baking-soda baths, calamine lotion, and antihistamines (diphenhydramine/Benadryl).
chicken pox is contagious from 2 days before the rash to until every blister has scabbed over.
chicken pox is dangerous to fetuses, but the rate of infection is lower than with other viruses. before 20 weeks of pregnancy, about 2% of fetuses become infected if the non-immune mother gets chicken pox; in the first trimester, only about 1%. effects to the fetus include permanent scarring of the skin, eye malformations, and nervous system problems (seizure disorder, intellectual disability).
there is no evidence that exposure to or infection with shingles (re-activated varicella) during pregnancy causes any of these problems.
chicken pox is most dangerous to newborn babies whose non-immune mothers were exposed to chickenpox within 2 weeks of birth. the reason for this is that the baby was born infected, before the mother’s own protective antibodies were developed enough to get into the fetus before the birth. about 25% of these babies die. it’s worst if the mom gets sick with symptoms 5 days or less before delivery.
a newborn who gets chickenpox after 10 days old is in much less danger (presumably because the mother’s antibodies got into its system before birth).
perinatal treatments:
– pregnant women who are not immune to chickenpox can be given immunoglobulin (concentrated anti-chickenpox antibody serum) +/- antiviral medicine, if they are exposed or if they get sick during pregnancy.
– a newborn can be given immunoglobulin +/- antiviral medicine if their mom got chickenpox 1 week before to 4 weeks after giving birth, or if their siblings have chickenpox and their mom is not immune.
– the newborn and mother do not need to be isolated from each other or from the baby’s siblings (breastfeeding is okay despite chickenpox).
complications: encephalitis is number one. there are two kinds associated with chickenpox: postinfectious encephalomyelitis (a.k.a. ADEM), and acute cerebellar ataxia.
see above in “measles” section to review postinfectious encephalomyelitis; remember, it causes fever, signs of meningitis (stiff neck), and sometimes seizures.
acute cerebellar ataxia does NOT cause fever, stiff neck, or seizures.
“acute” means sudden, “cerebellar” means the part of the brain that controls coordination, and “ataxia” means “can’t walk.”
it causes headache, vomiting, trouble with walking and talking, shaky eyes and hands. it does NOT cause one-sided symptoms or weak leg muscles with loss of reflexes. kids usually recover fully after a few weeks, without permanent nervous system damage.
both of these nervous system complications usually develop near the end of the first week of rash and are more common in kids aged 2-5.
varicella pneumonia is a rare complication in kids. it occurs much more often in adults who get chickenpox, with worsening fever, trouble breathing, and dry cough starting in the first week of the rash. the death rate of varicella pneumonia in adults is 10-30%. in pregnant women, varicella pneumonia is considered a medical emergency, with a death rate around 40%. presumably this is because women are in a somewhat immune-suppressed state during pregnancy.
it is possible to get chickenpox more than once, and when this occurs, it tends to run in families. some kids can still get chickenpox although they were vaccinated; they have milder illness and a lower complication rate, though.
a “varicella titer” (blood test for immunity) indicates whether you have had an actual chickenpox infection. if you were vaccinated as a child, the titer might be negative (and you may be poorly immune) as an adult. some people were only partly vaccinated (got one shot instead of two), and some of the vaccines may have worn off early.
stay tuned for part 3 – gastrointestinal childhood diseases, including polio, hepatitis B, and rotavirus.
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