Category Archives: Common Disorders In Infants And children
Central Nervous System Infections in Children (Meningitis & Encephalitis)
Viral infections of the central nervous system cause serious illnesses, some of them potentially fatal. They include Meningitis, which affects tissue layers enveloping the brain and the spinal cord, as well as Encephalitis, which is an infection of the brain.
- The main symptoms of viral central nervous system infections are fever and irritability; the child may refuse food, and in some cases, have seizures.
- Meningitis as well as encephalitis can be caused by viruses.
- Testing of the cerebrospinal fluid help diagnose the infection.
- Some viral infections of the central nervous system are not serious, but some others are potentially fatal.
- Treatment mainly involves supportive measures to help the body overcome the infection, since antibiotics as well as antiviral therapies are not very effective in eliminating the infections.
- Increasing fluid intake, and keeping the child warm, may help in overcoming the infection.
Several different types of viruses can cause infection in the brain and the meninges which enclose the brain and the spinal cord. Some of them are coxsackieviruses, arboviruses, and herpesviruses. Enteroviruses and echoviruses also cause infections of the central nervous system. Those infections which mainly affect the meninges which enclose the brain as well as the spinal cord are termed meningitis, which is very common among infants and children. When the infection is mainly affecting the brain, it is referred to as encephalitis. Encephalitis is not as common in infants as meningitis. If both the brain and the meninges are infected, it is termed as meningoencephalitis.
There are two ways in which viral infections can cause damage to the central nervous system. Viruses can infect the cells and destroy them at the time of acute illness. After the patient recovers from a direct viral infection in any part of the body, secondary damage may occur to the tissue surrounding the nerves due to the body’s immune reaction. The symptoms of this acute disseminated encephalomyelitis or post infectious encephalomyelitis may start appearing in the child many weeks after complete recovery from the original infection.
Viral infections of the central nervous system are acquired by children in different ways. For example; if the herpes virus is present in the secretions of the mother’s birth canal, it can infect a newborn infant as it passes through the birth canal at the time of delivery. People who have viral infections can disperse the virus into the atmosphere when they sneeze, cough and exhale air. When an infant or child is exposed to this air contaminated by virus-laden droplets, they can contract the infection. Insects infected with Arbovirus can spread the infection to children when they bite.
Older children as well as adolescents have symptoms similar to the ones adults with the same illnesses display. Their treatment is also similar in nature. Infants have immature immune systems which make them highly susceptible different infections at the same time, which makes it difficult to identify specific infections. Their inability to express many of their distressing symptoms makes the diagnosis even more difficult. However, certain characteristic symptoms are commonly observed in infants who have viral infections of the central nervous system.
Symptoms
Fever is usually the first symptom of a viral infection of the central nervous system in infants. In newborns, fever may be the only symptom present, and they may not even appear particularly ill. Infants one month of age, or older, may display irritability and fussiness. Refusal to feed and vomiting are the other common symptoms. Bulging out or tightening of the fontanelle, or soft spot present at top of the head, is another indication of the pressure build-up in the brain due to the infection. Movement worsens the pain and irritation of the inflamed meninges; hence, infants who have meningitis typically cry more when they are carried or rocked. An unusually high-pitched cry is another symptom that some infants have. Encephalitis usually causes seizures and uncontrolled movements in the affected infants. In severe cases of encephalitis, the infants become listless and lethargic. Coma and death may follow as the disease progresses. Herpes simplex infection usually affects a localized area of the brain, and may lead to weakness in a particular part of the infant’s body, besides causing seizures.
Post infectious encephalomyelitis which follows an episode of encephalitis can cause several neurologic problems which may either permanent or temporary. The symptoms depend on the location and the extent of brain damage that has occurred. Weakness of a particular limb, loss of hearing, blindness, mental retardation, and recurrent seizures, are some of the neurological disorders precipitated by this illness. They are usually recognized only much later when the child undergoes testing. Some of the symptoms eventually disappear, but some may be permanent.
Diagnosis
When a newly born infant has fever, doctors are alerted to the possibility of a central nervous system infection such as meningitis or encephalitis. If older infants have irritability or unusual behavior along with fever, they are also tested for these illnesses. The testing involves a lumbar puncture or spinal tap to retrieve a sample of the cerebrospinal fluid which is then analyzed in the laboratory to detect the cause of the infection. The absence of a bacterial infection, and the presence of abnormally high number of lymphocytes in the cerebrospinal fluid, is considered to be an indication of viral infections. Tests to detect specific antibodies against particular viruses are also done, but they are time-consuming. Enteroviruses and herpesviruses can be identified by a technique called polymerase chain reaction.
Electroencephalography which tests the electrical activity of the brain can help detect encephalitis due to a herpes virus infection. An MRI scan or a CT scan can confirm it. Occasionally, a biopsy of the brain may have to be done to detect the exact cause of the infection.
Prognosis and Treatment
Prognosis is greatly dependent on the type of virus causing the illness, and the severity of the infection. Children recover rapidly and completely from milder forms of viral meningitis as well as encephalitis with nothing more than rest and supportive care. However, certain types of infections are extremely serious, especially those caused by the virus called herpes simplex. The mortality among infants who have an infection of herpes simplex in the brain is around 15% with the best medical care. If some other parts of the body besides the brain are affected, it is often fatal in about 50% cases. Even among those who survive, 30% have permanent neurologic damage.
Supportive care is the main treatment for viral infections of the central nervous system. The child should be provided warmth and sufficient amounts of fluids, which may help the body to fight the disease. Antiviral therapy is not very effective in most cases of meningitis and encephalitis. However, if the infective organism is herpes simplex virus, the antiviral drug acyclovir is administered intravenously.
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Urinary Tract Infection in Children (UTI)
Urinary tract infection in children caused by bacteria include cystitis, affecting the urinary bladder as well as pyelonephritis, affecting the kidneys.
- Fever may be the only symptom of a urinary tract infection in newborns and babies.
- Older children may complain of a burning sensation or pain while urinating, wanting to pass urine more frequently, and sometimes, pain in lower abdomen.
- Bacteria are the cause of urinary tract infections.
- A urine test help diagnose the infection.
- Urinary tract infections are treated by antibiotic therapy.
- Maintaining good hygiene is important in preventing urinary tract infections.
Urinary tract infections of bacterial origin are a common occurrence in childhood. The bacteria causing the infection usually enter through the opening of the urethra, and move upwards, reaching the urinary bladder. From there they may spread to the kidneys too. In some rare cases, the infection in the kidneys may reach the blood and cause a widespread blood infection called sepsis. It can affect other organs too.
Among infants, boys are found to be more prone to urinary tract infections, but later on, girls have them more frequently. Girls are at a higher risk of contracting urinary tract infections because their urethras are short, and the bacteria can spread to other parts of the urinary tract faster. In boys, the bacteria which accumulate below the foreskin make those who are uncircumcised to be at greater risk of UTIs. Children who frequently have constipation may have urinary tract infections more often.
Infants and young children who develop urinary tract infections may be having certain structural defects in their urinary tract which make them vulnerable to infections. For example, vesicoureteral reflux, which is caused when a defect in the ureters which carry the urine from the kidneys to the bladder allow backward flow of urine, can take the bacteria from the bladder to the kidneys. Blockages in the urinary tract can result in the stagnation of urine that causes the bacteria to multiply. It has been found that half of the newborns and babies who have urinary tract infections have some structural defects too. In young schoolchildren also, up to 30% of those who have UTIs are found to be having some kind of abnormality in their urinary system. However, older children as well as adolescents have UTIs similar to that of adults.
In about half the infants and young children who have urinary tract infections, especially if they have fever, the kidneys are affected besides the urinary bladder. Infections in the kidneys may cause scarring of the tissues, which can lead to high blood pressure in adulthood. Scarring can impair kidney function later in life too. Severe vesicoureteral reflux can also cause scarring.
Symptoms and Diagnosis
Most of the newborns and babies with urinary tract infections may not have any symptoms except fever. A few may have vomiting or diarrhea. Lethargy and poor feeding are the other common signs.
Burning sensation and pain during urination is the most common symptom in older children. They may have an urgent need to pass urine, and urinate more frequently, but sometimes, they may find it hard to pass urine, and may feel a pain in the lower abdomen. Incontinence, or lack of control over urination, is another symptom. The smell of the urine may change to either too strong or foul. If the kidneys are affected, there is usually pain at the back, or at the sides, in addition to fever, malaise, and chills.
A urine test can detect urinary tract infections. The urine sample for testing should be collected carefully to avoid contamination. The urethral opening should be cleaned well before asking the child to urinate into a sterile cup. Children who are too young to urinate on request may require catheterization to collect a urine sample. A thin plastic tube is inserted into the bladder through the urethral opening to draw out a sample. Urine sample may be collected from newborns and babies by inserting a needle into the bladder through the skin, as samples collected by taping a plastic bag to the genital area are usually too contaminated for testing.
When the urine sample is examined under the microscope, bacteria and white blood cells may be detected, if infection is present. Chemical analysis of the urine is also done. Urine sample is then cultured to identify the type of bacteria that is causing the infection. The result of urine culture is very important in the treatment of UTI.
When an infant or a child has UTI, detecting the bacteria causing the infection, and eliminating it, is not sufficient. Girls below 2 years of age, and boys irrespective of their age, need to undergo further investigations to detect structural defects in their urinary tract that may have made them prone to the infection. In older girls with recurring infections also, the underlying cause needs to be identified. An ultrasound scan can detect structural defects and obstructions in the urinary tract.
Voiding cystourethrography is a test in which a dye is introduced through a catheter which is passed into the bladder via the urethra. X-rays taken before urinating, and after passing the urine, can identify abnormalities of the urinary tract as well as the occurrence of partial reverse flow of urine. In a test called radionuclide cystourethrography, a radioactive material is introduced into the bladder, and a nuclear scanner is used to obtain images. The advantage of this test is that radiation exposure of testes or ovaries can be minimized when compared to voiding cystourethrography. However, images obtained by radionuclide cystourethrography are not as sharp as those produced by x-rays taken during voiding cystourethrography. If the child is diagnosed with pyelonephritis, a special nuclear scanning is often employed to determine the extent of scarring of the tissues.
Prevention and Treatment
Maintaining high standards of hygiene may help prevent urinary tract infection in children. Girls should learn to wipe their bottoms from front to back after bowel movements, and not the other way, so that the fecal bacteria are not introduced into the urethral opening. Bubble baths may irritate the tender skin surrounding the urethral opening and make it vulnerable to infections. Both boys and girls should avoid frequent bubble baths to reduce the risk of urinary tract infections. Circumcision or removal of the loose foreskin in boys is found to lower the risk of UTIs by10 times, but it is not clear whether this procedure has any significant advantage over keeping the area under the foreskin clean by regular washing. Urination and bowel movements at regular intervals, and proper cleaning afterwards, may help reduce the occurrence of UTIs.
Antibiotic therapy is used for treating urinary tract infection in children. When the culture results have identified the particular type of bacteria causing the infection, the doctors can treat it more effectively with specific antibiotics. However, if a child who is diagnosed with UTI by preliminary testing is severely ill, the treatment is started immediately with a general antibiotic, without waiting for the results of the urine culture. The drugs are given intramuscularly or intravenously in cases of severe infection. For milder infections, oral antibiotic therapy may be sufficient. Antibiotics are continued for one to two weeks to ensure complete elimination of the infection. If the child is undergoing further testing to identify structural defects, lower maintenance doses are given till those tests are completed.
Some mild defects do not require any treatment as they may eventually get resolved without any medical or surgical intervention. In some cases, surgical correction of the structural defects may be necessary to avoid infections recurring. Some children may need a daily dose of antibiotic to protect them from repeated infections.
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What Is Rheumatic Fever
What Is Rheumatic Fever ?
Rheumatic fever is an inflammatory condition occurring in the joints, heart, and other organs of the body, following a throat infection by streptococcal bacteria.
- Rheumatic fever develops as a reaction to a throat infection caused by the streptococcal bacteria.
- Children developing rheumatic fever usually have joint pain and fever. Rashes and bumps below the skin, palpitations, pain in the chest, and jerky movements, also may be may occur.
- The typical symptoms help diagnose this illness.
- Treating throat infections due to streptococcal bacteria with antibiotics help prevent the development of rheumatic fever.
- Long-term antibiotic therapy is employed to eliminate the infection and aspirin is used as a pain killer.
Rheumatic fever is not an infection, but an illness resulting from an adverse reaction to a streptococcal infection called strep throat. Several parts of the body may develop an inflammation following the streptococcal infection. The joints and the heart are the most affected. The nervous system and the skin are also often involved. Most of the inflammation subsides gradually without causing any permanent damage. However, in some cases, rheumatic fever may cause irreversible damage to the heart.
In developed countries like the US, the occurrence of rheumatic fever has become rarer now because of early detection of strep throat, and the use of antibiotics for treating it. However, it may occasionally appear in certain areas, especially in overcrowded places. A hereditary factor is also found to be responsible. In developing countries rheumatic fever is still very common due to inadequate detection and treatment of strep throat. Not everyone who has a streptococcal infection develops rheumatic fever. For example, in the US only less than 3% of children with untreated strep throat develop this condition. Children who are affected once have a higher chance of developing rheumatic fever a second time, with about 50% of them getting it if a subsequent strep throat is left untreated.
Besides throat infection, the streptococcal bacteria can cause infections in other parts of the body too, including an infection of the skin called impetigo. But these infections are not followed by rheumatic fever.
Symptoms
Rheumatic fever can have various symptoms depending on the parts of the body which are affected by the inflammation. The throat infection may subside within a few days, but the symptoms of rheumatic fever usually start to appear several weeks later. Fever accompanied by pain in the joints and the chest, and palpitations, is the initial symptoms in most cases. The palpitations and chest pain are the result of an inflammation of the heart, referred to as carditis. Other symptoms may include a skin rash, small nodules below the skin, and a condition called Sydenham’s chorea, which is characterized by jerky, unintentional movements. All these symptoms may not be present in every patient.
Joints: Fever accompanied by pain in the Joints is the initial symptom of rheumatic fever. Pain and tenderness may occur in more than one joint at a time. The inflamed joint may be swollen and red in color and may feel hot to touch. Joints of the arms and legs such as elbows, wrists, knees and ankles are the most common sites of inflammation. Hips and shoulders, as well as the small joints of the fingers and toes, also may be inflamed. Migratory pain is a typical feature; wherein pain seems to shift from one joint to another. The pain and inflammation may last for up to four weeks, but they do not cause any permanent damage to the joints.
Heart: Chest pain is the usual indication of heart inflammation, but in many cases, there may not be any external symptoms present, and the inflammation of the heart may go unrecognized for several years, till the damage caused to the heart is detected later in life. The chest pain typically results from the inflammation of the pericardium enveloping the heart. Some people may have an awareness of the heart beat, commonly called palpitations. The damage to the heart can cause heart failure, with symptoms such as nausea and vomiting, shortness of breath, stomach pain, a dry cough and fatigue.
The inflammation of the heart gradually subsides and completely disappears in about five months. However, the damage to the heart, mainly to the heart valves, is irreversible, and precipitates a condition referred to as rheumatic heart disease. The extent of the initial inflammation of the heart determines the severity of rheumatic heart disease. Among those who had only a mild inflammation, about 30% people develop this condition, while severe inflammation often results in rheumatic heart disease in more than 70% of the cases. In 1% of cases, rheumatic heart disease may occur without any heart inflammation. The mitral valve which lies between the left atrial chamber and the left ventricle is the most commonly affected heart valve. The narrowing of this valve, known as mitral valve stenosis, results in leaking around the valve, referred to as mitral valve regurgitation. The heart murmur resulting from valve damage often help the doctor detect rheumatic fever. Valve damage can result in atrial fibrillation and heart failure later on.
Skin: A rash known as erythema marginatum may develop after some of the other symptoms disappear. The rash is painless and is flat with wavy edges. It does not last long; sometimes disappearing the same day it occurred. Those who had inflammation of the joints and the heart may have hard but painless nodules below the skin, often near the joints which were inflamed.
Nervous System: Sydenham’s chorea is a symptom which occurs in children with rheumatic fever if their nervous system is affected. Uncontrollable, jerky movements usually start after other symptoms of the illness have disappeared. The chorea starts gradually, but it steadily increases in intensity. The affected children are often brought to the doctor almost a month after the symptoms first appeared, usually when jerky movements have become rapid flailing of arms and legs. The hand muscles are the first to be affected, but it soon spreads to the feet. Any muscles of the body, except the eye muscles, can be affected. Uncontrolled grimacing results when the facial muscles are affected. However, these jerky movements are absent when the child sleeps. Clumsiness resulting from the lack of control of the muscles can make eating and dressing difficult and clumsy. In some cases, the condition becomes so severe that the children are at risk of injuring themselves. Chorea can last from about four months to eight months.
Diagnosis
The characteristic symptoms help the doctor diagnose rheumatic fever. High levels of the antibody against streptococci bacteria in the blood is an indication of rheumatic fever, but it is not taken as conclusive evidence, as many children without this illness also have these antibodies, although the levels may be lower. An ECG may show abnormal heart rhythms if the heart is inflamed. Damage to the heart valves can be detected by an echocardiogram, which produces an image of the heart with the help of ultra sound.
Prevention and Treatment
Rheumatic fever is best prevented by treating throat infections due to streptococcal bacteria with antibiotics. The treatment should ideally start as soon as the infection occurs, and the antibiotics should be continued till the infection is completely eliminated.
Those who have already had rheumatic fever following a strep throat should continue antibiotic therapy to avoid future episodes. A daily dose of penicillin can be taken orally, or monthly intramuscular injections can be administered. Duration of the treatment depends on how severe the illness is. Most children continue penicillin till they reach adulthood, but in some cases, especially if there is significant heart damage, and if chorea had been one of the symptoms, life-long therapy is recommended. Those who closely interact with children are also required to continue penicillin for life, as children generally have streptococcal infections which can be cause re-infection in adults with a history of rheumatic fever.
The three main aims of the treatment are:
- Completely eliminating the streptococcal infection.
- Reducing joint inflammation and the inflammation of the heart.
- Limiting the stress on the inflamed areas through complete bed rest.
When rheumatic fever is diagnosed, long-acting penicillin injection is given to the children to completely eliminate the infection. The pain and inflammation of the joints and the heart is relieved by high doses of aspirin. Naproxen and other non-steroidal anti-inflammatory drugs are also effective in bringing down the pain and inflammation. If the child has severe inflammation of the heart, corticosteroids like prednisone are also given to reduce it.
When the heart and the joints are in inflamed condition, bed rest is advised to avoid additional stress to the affected parts. Absolute bed rest, except for going to toilet, is essential if the child has inflammation of the heart.
If rheumatic fever has damaged the heart valves, the person always remains vulnerable to endocarditis or an infection of the valves. They should have antibiotics prior to undergoing any surgery or dental procedures as a precautionary measure against developing endocarditis.
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Retropharyngeal Abscess
Retropharyngeal abscess is a pus accumulation resulting from an infection in the lymph nodes present at the back of the throat.
- Throat pain and fever, accompanied by a stiff neck, difficulty in swallowing, and a characteristic noise while breathing, are the symptoms.
- Bacterial infections are the cause of retropharyngeal abscess.
- The typical symptoms help diagnose the condition; an x-ray and CT scan of the neck can confirm the diagnosis.
- Timely medical intervention and treatment help avoid complications.
- Treatment involves surgical draining of the abscess as well as antibiotic therapy to overcome the infection.
The bacterial infection which causes retropharyngeal abscess usually originates in the tonsils, sinuses, nose, adenoids, or the middle ear. Injury to the throat from objects swallowed, such as a fish bone or some other sharp object, can also lead to retropharyngeal abscesses. This condition mainly occurs in children because adults do not have these lymph nodes at the back of the throat, as these lymph nodes disappear as children grow.
Symptoms and Diagnosis
Retropharyngeal abscess may cause symptoms such as severe sore throat and fever, often accompanied by a stiff neck. Children may complain of pain and difficulty when swallowing, and keep their head tilted. They may start drooling; their voice may be muffled too. If the abscess is blocking the airway, breathing can be difficult, and the child may find that keeping the head, as well as the neck, tilted backwards while lying on the back make it easier to breathe. Inhalation is often accompanied by a characteristic noise referred to as stridor.
If retropharyngeal abscess is not diagnosed and treated early, complications may develop. The abscess can bleed around the edges, or rupture into the airway, causing blockage. It may trigger laryngeal spasms which can make breathing even more difficult. Pneumonia is another dangerous complication. The infection can spread to the chest also. There is a risk of blood clots developing in the jugular veins. If the infection spreads to the blood, it can cause widespread malfunctioning of the vital organs, precipitating a condition referred to as septic shock.
When children have sore throat, fever and noisy breathing along with a stiff neck, the doctor may suspect retropharyngeal abscess, and further investigations are done. An x-ray of the neck and a CT scan can diagnose the illness accurately.
Treatment
When treatment is started early enough, retropharyngeal abscesses do not cause serious complications in children. In most cases, surgical drainage of the pus may be necessary in addition to the antibiotic therapy to eliminate the infection. Intravenous administration of the antibiotics such as ampicillin-sulbactam, clindamycin, or cefoxitin, is used to treat the condition initially, followed by oral medication.
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Acute Epiglottitis
Acute Epiglottitis is an infection caused by certain bacteria to the epiglottis, which is the flap over the windpipe. Enlargement of the epiglottis can obstruct the airway, resulting in a potentially fatal condition.
- Sore throat accompanied by fever, occurring suddenly in a healthy child, is the first sign of epiglottitis. Difficulty in swallowing food and breathing, anxiety, confusion, and irritability, are the other common symptoms.
- The typical symptoms, and an x-ray showing the enlargement of epiglottis, help diagnose the disease.
- Certain bacteria are responsible for epiglottitis.
- Vaccination against the bacteria causing epiglottitis can protect the children from this disease.
- Children with epiglottitis require hospitalization, as the treatment involves keeping the airway open to facilitate breathing, in addition to the antibiotic therapy to overcome the infection.
Epiglottis covers the opening of the larynx and the trachea when the food is being swallowed, thus preventing the entry of the food particles into the airway. This flap of tissue can get infected by certain common bacteria such as Haemophilus influenzae type b, as well as certain strains of staphylococci and streptococci. Before the vaccine against Haemophilus influenzae type b became routine, epiglottitis was prevalent in children in the age group 2 to 5 years. If the affected children have bacteremia or presence of bacteria in their blood, the infection can affect other parts of the body such as the lungs, the meninges enveloping the brain, the pericardium enclosing the heart and tissues under the skin and in the joints.
In adults, different strains of staphylococci and streptococci bacteria, including Streptococcus pneumoniae are responsible for the infection.
Symptoms
Acute Epiglottitis often appears suddenly as a sore throat accompanied by high fever in a child who was previously healthy. Irritability and anxiety are often present. The child’s condition deteriorates fast with the rapid progress of the disease. Difficulty in breathing, and swallowing food, develops, leading to drooling and rapid breathing. The child may lean forward and stretch the neck backward in an attempt to increase the air flow into the lungs. Inhalation is accompanied by a characteristic loud noise called stridor. The blood oxygen levels decrease and carbon dioxide builds up in the blood. This causes symptoms such as confusion, anxiety, and, later on, lethargy. Because of the enlargement of epiglottis, the child cannot cough up the mucus. The swelling narrows the airway, and may even completely block it, cutting off breathing. Without immediate medical intervention, epiglottitis may cause death.
Diagnosis
Acute Epiglottitis is a potentially fatal condition, and it is treated as a medical emergency. When the doctor suspects epiglottitis, the child is immediately hospitalized, and the treatment is initiated as soon as possible. Examining the tongue with a tongue- depressor is avoided, as it may trigger throat spasms which can cause complete blockage and impede breathing. If the child does not seem very ill, and some of the typical symptoms of the disease are absent, the doctor may take an x-ray to check for the enlargement of epiglottis and confirm the diagnosis.
If the child is very ill, and the x-ray shows enlargement of the epiglottis, the child may be examined with a laryngoscope after administering anesthesia. This flexible viewing tube helps the doctor observe the larynx directly.
Prevention
Preventing epiglottitis through vaccination is better than treating the disease. Conjugate vaccines against the bacteria Haemophilus influenzae type b as well as Streptococcus pneumoniae are effective, and help prevent this potentially fatal condition.
Treatment
During physical examination, if epiglottitis is detected, or if the procedure causes throat spasm in the child, an endotracheal tube is introduced into the trachea to keep the airway open. In some cases, the endotracheal tube cannot be inserted into the tracheal tube due to severe swelling of the epiglottis. A surgical procedure called tracheostomy may be necessary in such cases. A small cut is made in the front part of the neck and the tracheal wall to insert the tube, which remains in place till the swelling subsides. Once the airway is free, the child is out of danger. Antibiotics therapy using drugs such as ampicillin-sulbactam or ceftriaxone can eliminate the infection.
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What Is Diphtheria
What Is Diphtheria ?
Diphtheria is a bacterial infection caused by Corynebacterium diphtheria. This highly contagious disease affects the upper respiratory tract, and can be fatal in some cases.
- Fever, sore throat, and a feeling of illness are the first symptoms. Lymph nodes may be swollen and a typical pseudo membrane can be seen in the throat.
- Serious diphtheria disease mainly occurs in children, but it has become rare in developed countries.
- The typical symptoms, especially the pseudo membrane and the inflammation in the throat, help diagnose the disease.
- An infected child is admitted in the hospital and treated in isolation until the infection is completely eliminated.
- Infection of the diphtheria bacteria can be prevented by vaccination.
Diphtheria used to be one of the major causes of childhood mortality in the past. Vaccination against the disease has been very effective, and diphtheria has become a rare occurrence among children in the developed countries like the US, where less than 5 cases are reported in a year. However, the bacteria causing diphtheria have not been completely wiped out, and if vaccinations are not continued, an outbreak of this highly contagious disease can occur anytime.
The diphtheria bacteria are present in the mouth as well as the throat of the infected person. They are spread into the surrounding air through coughing. These bacteria named Corynebacterium diphtheriae can multiply in the mouth, usually on the mucous membranes lining the mouth and the throat, causing inflammation and sore throat. Some types produce a toxin that can affect the nervous system, the heart, and the kidneys, and cause severe damage. Another type of diphtheria, mainly occurring in adults with poor personal hygiene, affects the skin, but it is milder. It’s common among the poor and the homeless.
Symptoms and Diagnosis
One to four days after the child is exposed to the bacteria, the disease may begin with symptoms such as high fever and sore throat. Malaise, or a feeling of being ill, may be present. The temperature may be as high as 103° F (39.4° C), and the fever may be accompanied by headache and chills. Nausea and vomiting may be present. Heart rate becomes fast, and the lymph nodes in the neck may become swollen and painful to touch. Inflammation in the throat may cause the narrowing of the airway, which results in severe breathing difficulty.
A typical characteristic of diphtheria is the formation of a tough membrane in the throat. This grayish skin is made up of remnants of the white blood cells and the bacteria among other substances, and is referred to as pseudo membrane. It may cover the tonsils as well as the throat, and makes the airway narrow. It can completely block the airway if it gets detached, suffocating the child. The diphtheria toxin can affect the nerves, particularly the nerves which control the muscles of the throat and the face causing difficulty in swallowing. Eye movements also can be affected. Arm and leg muscles may be affected too. If the toxin affects the cardiac muscles, a condition called myocarditis results, which may lead to abnormalities in the heart rhythm and heart failure. It can have a fatal outcome also.
When the doctor finds the pseudo membrane when examining a child with sore throat, diphtheria is suspected. If there are signs of paralysis of the muscles in the face or the throat, and the child had not received diphtheria vaccine, the diagnosis of diphtheria is given. A throat swab culture is done to confirm the diagnosis.
Prevention and Treatment
Routine vaccination against diphtheria is administered to children to prevent this disease. Usually, a combined vaccine called DPT against diphtheria, tetanus, and whooping cough or pertussis, is given.
When a child is diagnosed with diphtheria, immediate hospitalization is necessary. The child is admitted to the intensive care unit, and is isolated from other patients to prevent the spread of the disease. The treatment involves antibiotic therapy as well as the administration of antibodies or antitoxins which can neutralize the toxin produced by the diphtheria bacteria. Erythromycin and penicillin are the antibiotics usually given, and they are continued for 14 days to ensure that the bacteria are completely destroyed. After the completion of the antibiotic therapy, two mouth and throat samples are taken and cultured to confirm the absence of the bacteria before the child is released from isolation.
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What Is Pertussis (Whooping Cough)
What Is Pertussis ?
Pertussis, which is commonly called whooping cough, is caused by a bacterium named Bordetella pertussis, This highly infectious disease is characterized by prolonged coughing fits with a whoop, which is a high pitched sound created when the breath is drawn in with force.
- The illness starts as a minor cold and progresses to coughing fits.
- The characteristic whooping sound of the cough helps diagnose the disease. Testing the mucus secretions from the throat or nose can confirm the diagnosis.
- Pertussis is an infectious disease caused by a bacterium and vaccination is effective in preventing children from contracting the disease.
- Recovery is slow, but most of the affected children become completely cured of pertussis.
- In severe cases, especially in infants, antibiotic treatment with hospitalization is necessary.
Pertussis used to be a very common childhood disease in most parts of the world before vaccination against this highly infectious disease became available. In developed countries like the US, it has become much less common, but complete eradication has not been possible. Every two to four years epidemics occur among people who are not vaccinated. In the developing world, whooping cough continues to affect thousands of children due to inadequate immunization measures.
Pertussis can be contracted at any age, but children are the most affected, with two third of the cases occurring in those below 18 years. The disease is very serious in infants, and babies below 2 years, as it can be fatal in about 2% cases, with the majority of deaths occurring in infants below 6 months of age. Pertussis does not provide immunity to those who have recovered from it, but if a second attack were to occur, it is often mild, and not easily recognizable as whooping cough. It may even be mistaken as a case of ‘walking pneumonia’ in adults.
When a person with whooping cough has a coughing fit, the bacteria spreads to the surrounding air through the droplets of saliva and mucus discharged from the person’s mouth. People inhaling these bacteria can become infected. After the first three weeks of illness the disease is no longer infectious even though the cough takes much longer to subside.
Symptoms
Pertussis typically has 3 stages spanning across 6 to10 weeks altogether. The initial stage has the symptoms of a mild cold such as runny nose and sneezing. The person usually has coughing at night and a feeling of illness or malaise. After a week or two, the disease progresses to its second stage which is marked by the severe coughing fits characteristic of the disease. The typical pattern is a series of five or more forceful coughs in quick succession, followed by a deep drawing of breath which produces a high-pitched sound known as the whoop. After a brief period of normal breathing, the coughing fit is repeated. Thick mucus is produced in large quantities and it may be either swallowed by children or bubble up at the nose. Children may vomit after a prolonged episode of coughing fits. Infants may have breathing problems such as extended periods without breathing, known as apnea, or choking. Their skin color may change to blue due to lack of oxygen. The final stage is that of a slow and steady recovery and it may take several weeks, or in some cases months, for the children to become completely free of the persistent cough and weakness.
Complications such as pneumonia and ear infections may develop in about a quarter of the affected children. In a few infants the brain may be affected, which may result in confusion and seizures. If brain damage occurs, it may result in permanent problems such as learning disabilities and mental retardation.
Diagnosis and Prognosis
When doctors encounter the typical whooping sound of the cough, pertussis is suspected, and a sample of the mucus from the throat or nose is cultured to confirm the disease. The test result may be accurate only in the first few weeks of the disease. If it is negative, a rapid detection test or polymerase chain reaction test may be conducted for confirmation.
Recovery from pertussis may be gradual, but eventually most children completely recover from the disease. However, children younger than 1 year carry about 2% risk of dying from whooping cough.
Prevention and Treatment
Vaccination against pertussis is routinely administered to children to protect them from the disease. Usually the combined vaccine DPT against diphtheria, tetanus and pertussis is given. When children are exposed to whooping cough, antibiotics such as erythromycin or orazithromycin may be given as a precautionary measure.
Hospitalization may be necessary if infants are severely ill with pertussis as they may need assistance with their breathing. A tube is inserted into the windpipe to provide ventilation. In less severe cases, oxygen masks may be used to provide extra oxygen. Fluids are administered intravenously. To prevent the spread of the disease, the infant is isolated till the antibiotic therapy for five days is completed. If the disease is mild, oral antibiotics are prescribed, and the child is sent home to recover. Usual cough medications are not effective against whooping cough, so they are not prescribed.
Erythromycin, azithromycin and clarithromycin are the antibiotics commonly used to treat pertussis. These drugs are effective against other accompanying infections such as ear infections and pneumonia too.
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Meningitis in Children
Bacterial meningitis in children is an infection affecting the meninges or the tissue layers covering the brain as well as the spinal cord.
- Headache and fever, accompanied by a stiff neck, and sometimes confusion, are the usual symptoms appearing in older children. In younger children and infants, irritability, vomiting and refusal to eat may be only indications.
- Sepsis or bacterial infections in the blood are the usual cause of bacterial meningitis.
- Spinal tap for the cultural analysis of the cerebrospinal fluid and certain blood tests help diagnose meningitis and identify the bacteria causing it.
- Meningitis can be fatal in some cases even with timely intervention and the best medical treatment.
- Vaccination against the bacteria causing meningitis can prevent the disease.
- Antibiotic therapy is the main treatment for bacterial meningitis.
Meningitis may occur at any time. However, the meningitis affecting newborns and very young infants is different from the type of disease occurring in older children and adults.
Children who are without a spleen and those who have sickle cell disease are at increased risk of developing meningitis. Certain congenital defects occurring in the bone structure of the skull and the face may make some children more susceptible to bacterial infection of the meninges or the tissue layers covering the brain. Children who have immune-deficiency while undergoing chemotherapy for cancer, and those who have AIDS, are also highly prone to bacterial meningitis.
Causes
Sepsis or a bacterial infection in the blood is the main cause of meningitis affecting newborn infants. Escherichia coli, Streptococci group B and Listeria monocytogenes are the most common causes of bacterial infections affecting the newborn. The infant usually picks it up at the time of its passage through the mother’s birth canal. Older children can contract the bacterial infection from the respiratory secretions of others who are infected. Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides, are the bacteria commonly causing meningitis in older children. Development of effective vaccines and their widespread usage against Haemophilus influenzae type b have significantly reduced meningitis due to them. Conjugate vaccines have been developed for Neisseria meningitides as well as Streptococcus pneumoniae, and they should make bacterial meningitis in childhood rare.
Symptoms and Diagnosis
Headache and steadily increasing fever, typically accompanied by a stiff neck, can be the indication of meningitis in children. Confusion is another symptom that may be present. An infection may be present in the upper respiratory tract, but it may not be related to the meningitis. Very young children and infants often stop feeding, and become very irritable especially when held. This is an important indication that should alert the parents of the possibility of meningitis since these infants do not usually develop a stiff neck and they are unable to express their discomfort. Fever may be accompanied by vomiting. A skin rash may appear in some. In about one third of the cases, seizures may occur. Damage to the facial nerves may cause a lopsided facial expression. The nerves which control the eye movements may be damaged too, resulting in one of them turning either outward or inward. Bulging of the fontanelles is another indication of meningitis in newborns. The increased pressure in the brain causes these soft spots present in the skull of infants to expand and become firm to touch. Symptoms appear over one or two days, but in very young infants and newborns the progression can be rapid, and their condition may become extremely critical within the day.
Occasionally, meningitis causes pus-filled pockets in the brain referred to as abscesses. These abscesses can get enlarged and exert pressure on the brain. The head may become enlarged and the fontanelles bulge out. It may result in nausea and vomiting too.
Bacterial meningitis is diagnosed by culturing the cerebrospinal fluid collected by doing a procedure called lumbar puncture or spinal tap. A blood sample is also cultured to check if the bacteria are present in the bloodstream also. An ultrasound scan or a CT scan is also performed to detect any abscesses in the brain.
Prognosis
Bacterial meningitis in newborns has a fatal outcome in one fourth of the cases, even with timely medical intervention. Older children have a better chance of survival, but the rate depends on the type of bacteria causing the disease. With Haemophilus influenzae type b infection, less than 5% of those affected succumb to the disease. Meningitis due to Neisseria meningitides carries a slightly higher fatality rate of up to 10%. Streptococcus pneumoniae is the deadliest, with up to 20 % of those with meningitis caused by these bacteria dying of the disease even with treatment.
Among the survivors, up to 25% suffer permanent brain damage which results in various neurological problems. Deafness, intellectual disabilities, cerebral palsy and mental retardation are some of the conditions precipitated by meningitis. Less severe problems such as mild hearing loss, learning disabilities and seizures may occur in about one third of the cases. The severity of the problems depends on the age of the child to a certain extent, with older children suffering less permanent damage and complications than younger children and infants.
Prevention
Bacterial meningitis can be prevented by vaccinating the infants and young children against Haemophilus influenzae type b as well as Streptococcus pneumoniae. Conjugate vaccines are available against these bacteria. Doctors and other health care providers should educate the parents and encourage them to get the children vaccinated. Neisseria meningitidis polysaccharide may be given to older children to prevent meningitis in them. Conjugate vaccine for Neisseria meningitidis is also available.
Treatment
Intravenous administration of antibiotics in high doses is the first step in the treatment of meningitis. Antibiotic therapy is started as soon as meningitis is suspected. If the child appears very sick, the treatment is initiated with general antibiotics even before performing the spinal tap. The particular bacteria causing the meningitis can be identified by the culture of the spinal fluid. Later, the antibiotics may be changed, and specific antibiotics given, based on the results of the culture. Corticosteroids are often given to children above one and a half months old to protect them from permanent neurologic damage. The spinal tap may be repeated, and the fluid is cultured again, to check if the antibiotic therapy is effective.
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Occult Bacteremia In Children
Occult bacteremia in children is characterized by the presence of freely circulating bacteria in the blood of young children who have no other specific source of infection elsewhere in the body. Fever may be the only symptom, and the child may not seem particularly ill.
- Fever may be the only symptom present in the affected child. Blood tests help diagnose occult bacteremia.
- Streptococcus pneumoniae is the most common cause of occult bacteremia.
- This infection is effectively treated with antibiotic therapy.
Fevers are very common in children below 3 years of age. They indicate some infection or inflammation in the body, and are usually accompanied by other obvious symptoms such as runny nose, throat pain or cough. These additional symptoms help the doctor to identify the cause of the fever. In about one third of the cases, any symptom other than fever may be absent. Viral infections are the usual reason in most of such cases, and the fever eventually subsides without any specific treatment. In about three percent of cases, fever may be caused by the presence of bacteria in the bloodstream. It is referred to as occult bacteremia, as the infection is hidden and can be detected only by blood tests.
A type of bacteria named Streptococcus pneumoniae is the usual cause of occult bacteremia in children. Neither adults, nor older children, usually have freely circulating bacteria in their blood without having any symptoms other than fever as an indication. The presence of bacteria in the blood raises the risk of developing dangerous infections in the different organ systems of the body. Even though less than 10% of young children who have occult bacteremia actually develop meningitis, pneumonia or such other serious illnesses, doctors try to identify the causative organism by culturing the blood, so that the infection can be treated before complications develop. If the WBC count is higher than normal, it indicates a bacterial infection. In such cases, the doctors may straight away initiate antibiotic therapy without waiting for the result of the blood culture.
Since only a blood culture can accurately detect occult bacteremia, any child below the age of 3 years, having a high fever without any other accompanying symptoms, is subjected to further investigations, to rule out this condition. The blood cell count is tested, and a blood sample is sent for culture. Children older than 3 years do not require blood culture as occult bacteremia is rare in older children.
When the results of the blood culture become available, usually within one or two days, the cases are reevaluated. If the result is positive for occult bacteremia, but the child is not visibly ill, oral antibiotics are prescribed, and the child is sent home. If the child appears severely ill, hospitalization may be necessary, and antibiotics are given intravenously. Severely ill children, and those who have high white blood cell count, may have been given a shot of an antibiotic drug like ceftriaxone, even before the culture results are ready. Such cases are also reassessed based on the results.
Vaccines have been developed to avoid occult bacteremia in children. A conjugate vaccine against Haemophilus influenzae type b, given to almost all young children in the US, has successfully wiped out occult bacteremia caused by type b Haemophilus influenzae. Another conjugate vaccine is also available, which provides protection from Streptococcus pneumoniae. When administered to infants, it has helped prevent occult pneumococcal bacteremia in them. Neisseria meningitidis is another bacteria causing occult bacteremia in young children. A newly developed vaccine against this type of bacteria is in the testing stage. Occult bacteremia is expected to be completely eliminated by the combined use of all these vaccines.
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Apparent Life Threatening Event In Infant (ALTE)
Apparent life threatening event refers to the sudden appearance of dangerous symptoms in otherwise healthy babies below one year of age. Apnea or a prolonged absence of breathing, gagging and coughing fits, change of muscle tone or skin color, are the usual symptoms associated with an apparent life-threatening event or ALTE.
- Certain infections and disorders of the nervous system are the usual causes of ALTEs.
- Feedback from parents and caregivers of the baby followed by a thorough physical examination, and certain diagnostic tests, help diagnose the condition.
- The cause of the ALTE determines the prognosis.
- Treatment depends on the cause, if it is identified.
Apparent life threatening event is not a disease, but often the symptom of some underlying disease in the baby which needs to be investigated.
Causes
Infections, brain tumors, meningitis, and other such disorders of the nervous system, and gastroesophageal reflux disease, are the usual causes of Apparent life threatening event. Less commonly, abnormalities of the heart, metabolic disorders, and narrowing of the airways or a complete blockage, may result in an ALTE. Occasionally, it may have resulted from child abuse. In about half the cases, it may not be possible to detect the exact cause.
Symptoms
An Apparent life threatening event often occurs without any warning, and the alarming symptoms shock the child’s parents or other caregivers. Some of the commonly occurring symptoms are:
- Absence of breathing for over 20 seconds
- Sudden change in color to blue or red, or becoming pale
- Muscle tone changes, usually the body becoming floppy, and less commonly, developing stiffness
- Gagging, choking or sudden fits of severe coughing
Diagnosis
Feedback from parents and caregivers play an important part in diagnosis. On bringing the child who has suffered an Apparent life threatening event to the doctor, the parents or other caregivers may be asked to explain the following in detail:
- The observation of the baby’s parents or caregivers who were present at the time of the Apparent life-threatening event regarding the changes which occurred in the breathing pattern, muscle tone, skin color, eyes and the general appearance.
- Whether the baby has had previous episodes of ALTE.
- The duration of the episode, and how it got resolved.
- Whether any first-aid procedures such as cardiopulmonary resuscitation, mouth-to-mouth breathing, or other methods of stimulation were done to revive the baby, and what they were.
- The drugs the baby’s mother had used during pregnancy, her current use of alcohol and drugs and the family’s tobacco usage.
- The gestational age of the baby, and whether the baby had prematurity or post maturity at birth.
- Whether there were any complications during delivery.
- Whether the baby has any feeding difficulties, and whether incidents of gagging, coughing fits, or bringing up food, occur frequently at the time of feeding.
- Whether the weight gain has been normal or poor.
- Whether the baby had any developmental delays or growth retardation.
- Whether the baby had suffered any physical trauma recently.
- Whether any other family member had an ALTE or whether any sudden death had occurred in the family.
A thorough physical examination is done with special emphasis on identifying abnormalities of the nervous system such as changes of muscle tone, either stiffness, which is termed posturing, or floppiness, referred to as poor muscle tone. Doctor may look for signs and symptoms of trauma also.
In addition to blood tests, urine and stool tests, liver function tests and imaging tests also may be done. A chest x-ray, ECG and a CT scan of the head are usually done. An electroencephalography is also done, if required.
Treatment
If the cause of Apparent life threatening event is identified, it can be treated. If the infant has required CPR for revival, or if any abnormality is detected by physical examination or by laboratory testing, hospitalization may be necessary to monitor the infant and evaluate the condition.
The parents of a child who has had ALTE should get trained in CPR, as well as safe infant care, including, how to place the infant on its back for sleeping, and ways to avoid exposing the infant to tobacco smoke. Other caregivers of the infant also should have proper training. An apnea monitoring device designed for home use may be recommended by the doctor. The apnea monitor sounds an alarm when there is a disruption in the breathing. Some monitors can record breathing pattern and heart beat as well, and they may help the doctor evaluate the ALTE better and distinguish it from false alarms