Posted tagged ‘enterovirus’

Hand-foot-and-mouth disease: Everything you need to know

June 1, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Desiree wrote in, “My 15 month daughter and a few other kids at her daycare were just diagnosed with hand-foot-mouth disease. I would like to hear how common it is, what treatments (or ways to soothe) you find helpful, and how you would differentiate this from measles or chickenpox.  For example, my little one has blisters all over her body, not just H-F-M.  What are other complications? Can she get it again?”

Hand-foot-and-mouth disease (HFM) is very common, bread and butter pediatrics. We see tons of it. It’s more common in the summer and early fall, so I’m not surprised that it’s already hit Desiree’s daycare.

HFM is caused by a virus in the enterovirus family, usually coxsackie A16. Those same viruses, as a family, can cause a wide range of other problems that sometimes overlap with HFM, so not every child in an HFM outbreak is going to get the classic HFM picture. Some will only have a fever, and some will only have ulcers in their mouths, and some will develop no symptoms at all.

The full picture of HFM begins after a 3-6 day incubation period, with fevers and blistery-looking spots mostly on the hands and feet. I say mostly, but many times there are more extensive rashes other places (I guess Hand-Foot-Mouth-and-Butt doesn’t sound dignified, but it’s true.) The spots on the hands and feet usually don’t cause any pain or other symptoms, but if they’re present in the mouth they hurt and make it difficult to eat and drink. Classically, all of the spots heal in a week or 10 days.

But: there’s a newer virus out there causing HFM, coxcsackie A6, which causes a more-widespread, more-severe rash that takes longer to heal. It also sometimes causes more of all of a child’s fingernails and toenails to fall off. They’ll grow back, but it can be striking and upsetting when it happens.

Most children only get HFM once, or if they get it again the later episodes are milder. However, with this new A6 going around, many children (or even parents) seem to be getting a full blown case again.

The main treatment for HFM is comfort. Give extra fluids, or popsicles, or ice cream, and painkiller/fever reducers like acetaminophen or ibuprofen. And then a milkshake, or a blueberry-banana smoothie.

Desiree wanted to know how we can tell it’s not chicken pox or measles. It’s usually not too difficult. Chicken pox is really itchy; and people with chicken pox get crops of new spots, so there are usually old ones and new ones scattered all over the body. People with measles are quite ill, with a bad cough and high fevers, often with red eyes. The rash of measles doesn’t look like blisters or ulcers—it’s more just flat red spots that run together.

Since summer is just starting, I’m sure we’ll be seeing more HFM soon. You can try to prevent it with good hand washing, especially after changing diapers—but in a day care center, with toddlers putting toys in their mouths, HFM is going to be difficult to stop. There’s no vaccine to prevent this one, and no specific treatment or antibiotics are going to make any difference. Desiree can have a milkshake, too, to help her and her kiddo make it through.

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Infection Report 4: Two newcomers and the importance of paying attention

October 9, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

While Ebola makes the headlines and influenza prepares its yearly visit, two other “new” infections have been brewing this summer. We’re still got a lot to learn about “the new respiratory virus,” AKA enterovirus D68, and whatever seems to be causing cases of paralysis in 9 kids in Colorado. It’s even possible that these two infections are the same. These infections are coming to light because hospitals and public health officials stay on the lookout for new patterns of disease and infections. It’s not complicated, and it’s really not rocket science. It’s all about paying attention.

Earlier this year, hospitals first in Illinois and Missouri reported an unusual spike in ER visits and hospitalizations for respiratory symptoms, including cough, wheezing, and difficulty breathing. Often, children with this infection became very sick very rapidly, requiring hospital or ICU-level care very shortly after the onset of symptoms. Most, but not all, affected individuals had pre-existing lung problems, mostly asthma. Though routine testing for a specific agent still isn’t widely available, laboratories were able to identify a specific viral cause, an “enterovirus” named D68. That virus has been around since at least 1962, but until this year hadn’t caused widespread infections. It’s probably spread throughout the United States, and continues to contribute to many hospitalizations.

Many children (and adults) with this infection probably have mild symptoms, indistinguishable for any other viral “cold”, but some go one to become seriously ill. By the way, that’s true for almost all ordinary cold viruses—though most people sail through those infections just fine, every once in a while an ordinary cold virus makes someone very, very ill. This new enterovirus isn’t really that different from many other respiratory viruses, but it’s newly widespread and seems to have a disproportionately high rate of complications.

Or maybe it is kind of different, after all. We’re also hearing reports out of Colorado of a new kind of illness, one that looks like an infection, that’s caused flaccid paralysis in at least 9 children (actually the CDC is investigating about 23 reports, though it’s not yet clear if all of these are the same condition.) Many of those children seem to have had a respiratory illness about 2 weeks prior to the onset of the paralysis. MRI scanning is showing changes in the part of the spinal cord that controls motor functioning, and in some ways the clinical presentation and MRI findings look similar to an old infection, poliomyelitis. But specific tests for polio virus have been negative.

Here’s an theory: this respiratory virus D68 and polio virus are related—they’re both from a large, diverse family of viruses called “enterovirus.” These viruses typically cause summer infections, and different kinds of enterovirus can cause disease of the gut, lungs, liver, nerves, skin—all sorts of things.  About half of the Colorado 9 children have tested positive for D68. That’s not definitive—that doesn’t mean D68 is causing the paralysis—but it’s certainly suggestive and interesting. It is possible that these two new things, the respiratory virus and the paralysis, are actually being caused by the same infection.

We’ll be learning more about these infections in the coming months. For now, the best steps available to protect your family are common sense things: wash hands, stay away from sick people, don’t touch your face, and beware of signs of bad respiratory disease. Though there are no vaccines for these new infections yet, you can prevent the return of polio and the widespread sickness of influenza with current, safe, effective immunizations. Hospitals, doctors, and staff at hospitals in the midwest did a great job in identifying these new problems and alerting public health officials to begin their investigation. Our health depends on all of us, together, paying attention to and confronting health threats like these.

Next: What you really need to worry about

Protect your kids from the “new” respiratory virus

September 10, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Facebook and other social media sites are all a-twitter (ha!) about a “new” respiratory virus, sweeping the country and sickening thousands of kids. There is something new, or new-ish, out there, and it looks like the infection can get pretty bad. But now is not the time for panic. We’ll get through this, like we get through other spikes in viral infections. With some common-sense steps, your kids will be OK.

As reported officially by the CDC this week, in the last month hospitals in Illinois and Missouri reported an increase in emergency department visits and hospitalizations for respiratory symptoms. Since then, reports of similar illness are coming in from many other states, scattered across the country. Most (but not all) of the cases with more severe illness had pre-existing lung disease (like asthma).

The illness seems to be mostly affecting children. Most cases begin with ordinary, cold-like symptoms—and it’s likely that most cases actually never develop into anything more than that. The reported cases, so far, may well be a “tip of the iceberg” effect, where only the sickest children get tested and identified. These are the kids who develop trouble breathing and low oxygen levels, and often need intensive care. It’s quite likely that most children with this infection quickly recover after a cough, sniffles, and runny nose. Of the cases reported so far, only about 1 in 4 or 5 runs a fever. Probably, most children and adults who have this infection don’t seek medical care, and very few of them (so far) are even being tested for the likely viral cause.

Most of the reported cases are testing positive for a specific virus, called enterovirus D68. That virus was first identified in California and 1962, and until now had rarely been a reported cause of illness. The enterovirus group, as a whole, contains a lot of other viruses that cause a whole bunch of different symptoms—fevers, respiratory illnesses, GI problems, heart disease, rashes, and neurologic problems. Pediatricians and others who take care of kids are used to seeing tons of enterovirus, which usually strikes in the summer, most typically as hand-foot-and-mouth disease, or as a fever. So we’re used to these kinds of viruses, even though this specific one is a newly-recognized member of the family. We’re not 100% sure, yet, exactly how D68 is transmitted, but other enteroviruses spread though respiratory drops and in stool, and can remain infectious for a long time on contaminated surfaces.

As with many viral infections, prevention is the best strategy. Common sense things can really help: keep your kids home when they’re sick, and don’t send your kids off to play with sick children. Encourage your kids to wash their hands and use hand sanitizer frequently. Get a good night’s sleep and moderate exercise. Keep your child up-to-date on vaccines—though there is no specific vaccine for this enterovirus*, bacterial and viral coinfections with influenza and pneumonia can be prevented. If your child has asthma (or any other respiratory problems), make sure that you’re keeping up with all prescribed treatments, so things are less likely to spiral out of control when an infection strikes.

If your child does get sick with cough, look out for these symptoms:

  • Having trouble breathing. You may see individual ribs poking out with each breath, or the depression at the bottom of the neck sinking in, or bobbing up and down. Children with trouble breathing usually breathe fast, and sometimes breathe noisily.
  • Having trouble speaking. If you can’t get good breaths in, you can’t typically complete sentences and talk normally.
  • Seeming listless, with low energy. Children with serious respiratory compromise may not be getting enough oxygen to their brains. They can seem “foggy” or “out of it.”
  • Drinking poorly. Younger children and babies may have a hard time eating and (especially) drinking when they’re really ill.
  • Looking blue or pale.

If you’re seeing those kinds of symptoms, take your child to the doctor right away, or head to the emergency department. Even if things don’t seem quite that bad, if you’re worried, don’t hesitate to call for help.

Most children who are getting enterovirus D68 infection will do just fine. Some of you have probably already had children with this, and didn’t even know it. Every year, we see spikes of infections like this, caused by a variety of viruses like RSV, metapneumovirus, or influenza. Though there is no specific therapy for most of these, we’re pretty good at recognizing who needs extra help, and we can provide good supportive care when it’s needed. It sounds scary when you see news of a new, bad infection—but in truth, this isn’t very different from other infections we’re used to dealing with. We need to stay vigilant and keep our eyes on whatever’s out there making our children sick, but there’s no reason to get too worked up over this latest challenge.

*Fun trivia challenge: we routinely vaccinate against one other enterovirus, one that historically caused infections in the summertime. Guess!

This was adapted from a post I wrote for my practice website.