Is Enterovirus D68 A New Virus?

Patient Presentation
A 3-year-old male came to clinic with fever, runny nose and cough for 36 hours. His parents had treated him with ibuprofen which helped but they felt he was now wheezing. He had no history of asthma or other respiratory problems. He did attend day care and there had been several other children with similar illnesses, and enteroviruses were circulating in the community. He was drinking and urinating well. The past medical history showed upper respiratory tract infections and some otitis media. The family history was negative for asthma, but there was an elderly uncle with chronic obstructive pulmonary disease. The review of systems was negative including for rashes.

The pertinent physical exam showed he was mildly ill-appearing with a fever of 38.2°C., respiratory rate of 28/minute, pulse of 104 beats/minute and growth parameters that were 75-90% for age. HEENT showed clear rhinorrhea, mildly erythematous pharynx, and clear tympanic membranes. His lungs had some transmitted upper airway sounds, but also some mild end-expiratory wheezing at both bases. Skin examination showed no rashes. The diagnosis of a viral infection, that was triggering mild bronchospasm was made. The patient’s clinical course in the clinic showed him to have resolution of the bronchospasm after treatment with albuterol. The family was instructed to provide supportive care and was shown how to use an albuterol metered-dose inhaler with a spacer device. They were also instructed on how to look for respiratory distress and to call if he was having more problems. At an appointment a few weeks later, his mother says that he used the albuterol for about another 2 days and then the symptoms had resolved.

Discussion
Enteroviral infections are RNA viruses including Coxsackieviruses A and B, Echoviruses and Enteroviruses. They are common and spread by respiratory secretions, fecal-oral contamination and fomites. They commonly occur in summer and fall in temperate climates but are less seasonally seen in the tropics. Hand hygiene is especially important to prevent infection. The incubation period is usually 3-6 days. The viruses are best isolated from the throat, stool and rectal swab specimens but other infectious sites can also be used for viral isolation. Treatment is supportive. Infants, children and teens are more likely to be infected but all ages can be infected as these are very common viral illnesses.

Common symptoms of enteroviral infections include fever, upper respiratory symptoms such as rhinorrhea, cough and sneezing, rashes and mouth ulcerations, body and muscle aches and conjunctivitis. Other less common problems include viral meningitis and encephalitis possibly with paralysis, and myocarditis and pericarditis.

Enterovirus D68 (EV-D68) is a non-polio enterovirus that usually causes fever, rhinorrhea, cough, sneezing, and body and muscle aches.

Learning Point
In the summer of 2014 the United States has had an outbreak of EV-D68 and it appeared early in the Midwest where this patient was seen. Although the patient was not tested, in retrospect this patient was probably an early case of EV-D68.

EV-D68 is not a new virus but was originally isolated in 1962 in California and has rarely been reported in the US, except for small clusters. In 2014, the outbreak has caused many children to have severe respiratory illnesses. It affected children with and without a previous history of asthma, and many needed admission to intensive care for aggressive respiratory support.

Questions for Further Discussion
1. What diagnostic tests are available to detect EV-D68?
2. What epidemiological surveillance systems does your country have for monitoring enteroviral infections?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Viral Infections

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Centers for Disease Control. Symptoms.
Available from the Internet at http://www.cdc.gov/non-polio-enterovirus/about/symptoms.html (rev. 5/10/14, cited 9/26/14).

MMWR. Severe Respiratory Illness Associated with Enterovirus D68 – Missouri and Illinois, 2014
September 12, 2014 / 63(36);798-799.
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6336a4.htm?s_cid=mm6336a4_w (rev. 9/12/14, cited 9/26/14).

Centers for Disease Control. Enterovirus D68.
Available from the Internet at http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html (rev. 9/25/14, cited 9/26/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Factors Decide Urolithiasis Treatment?

    Patient Presentation
    A pediatrician saw two patients with urolithiasis over two weeks that had been managed differently and she wondered what were the factors that had been used for their treatment decisions. The first was a 17-year-old female who was traveling by car and had exquisite abdominal and flank pain that became worse and caused the family to seek care at the nearest hospital along the road. The diagnosis was made by computed tomographic scan and the patient was taken to the operating room for removal of the stone “just above my bladder” and placement of a stent. Her medical records showed that it was a 7 mm calcium oxalate stone causing mild hydronephrosis just above the ureterovesical junction. The stent was removed 10 days later and she had been doing well since. The second patient was an 8-year-old male who had sudden onset of abdominal and flank pain and was seen in the local emergency room. A 3 mm stone located above the ureterovesical junction that was not causing hydronephrosis was diagnosed by computer tomography. The patient responded to IV fluids and pain management in the emergency room and was discharged home. The pain resolved within 48 hours but the stone was not collected. Both patients underwent further metabolic evaluations for causes of the urolithiasis formation.

    Discussion
    Although pediatric uroliathiasis is relatively rare, there has been an increasing number of children evaluated for renal stones over time. For an overview of uroliathiasis click here.

    Renal colic classically has paroxysmal pain that is severe, radiates toward the groin and the patient is not able to find a comfortable position. They may also have irritability, nausea, emesis, increased urinary frequency, dysuria and hematuria. 85-90% of patients will have macro- or microscopic hematuria but up to 15% of patients with urolithiasis will not have hematuria.

    Clinical differential diagnosis includes but is not limited to:

    • Appendicitis
    • Constipation
    • Gastroenteritis
    • Intussception
    • Ovarian torsion
    • Urinary tract infection

    The most common locations for stones to lodge are the ureteropelvic junction, the ureterovesical junction and where the ureter crosses the common iliac vessels.

    Learning Point
    Size and location of the stone and if it is causing urinary obstruction guide treatment decisions. Stones that are smaller than 4 mm and that are non-obstructing are usually managed conservatively. Those that are larger than 4 mm or causing obstruction usually require interventional management. Stones that are higher up in the urinary tract are more likely to require intervention. If initially treated conservatively and after 3-6 weeks the patient’s stone has not resolved then interventional treatment is usually indicated.

    Conservative management includes aggressive hydration, pain management and nausea/emesis management. In the emergency room IV hydration at 1.5-2.0 times maintenance, pain management with narcotics and non-steroidal antiinflammatory medication (i.e. morphine and ketoralac) and management of nausea and emesis by IV medication are the standards of care. If the patient improves then they may be discharged to continue aggressive oral hydration and pain management.

    Interventional management includes extracorporeal shockwave lithotripsy which is good for a variety of stones and locations but is limited in lower kidney pole locations, with staghorn stones or patients with abnormal urinary system anatomy. Percutaneous nephrolithotomy is good for large lower kidney pole stones or staghorn stones. Endoscopy is good for distal ureteral stones and especially if less than 15 mm in size. Ureteral stents may be placed until post-operative edema resolves (generally 1-2 weeks)

    Recurrence rate of calculi is 24-33%.

    Questions for Further Discussion
    1. What are the most common types of kidney stones?
    2. What metabolic evaluations should be considered for patients with kidney stones?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Kidney Stone.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Wu HY, Docimo SG. Surgical management of children with urolithiasis. Urol Clin North Am. 2004 Aug;31(3):589-94, xi.

    Cameron MA, Sakhaee K, Moe OW. Nephrolithiasis in children. Pediatr Nephrol. 2005 Nov;20(11):1587-92.

    Schissel BL, Johnson BK. Renal stones: evolving epidemiology and management. Pediatr Emerg Care. 2011 Jul;27(7):676-81.

    Granberg CF, Baker LA. Urolithiasis in children: surgical approach. Pediatr Clin North Am. 2012 Aug;59(4):897-908.

    ACGME Competencies Highlighted by Case

  • Patient Care
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Legal Issues that Affect Health?

    Patient Presentation
    An 8-year-old Hispanic male came to clinic for his well child care. His mother had no concerns except that he was not doing as well in second grade as she had wanted. He had received English-language learner (ELL) services during kindergarten and first grade, but they were stopped when he entered 2nd grade. He had always struggled with reading she said. The teacher said that he didn’t qualify for ELL services anymore and there were no other additional services for him. She recommended going to the library and having him read to his mother at home. His mother had tried this but had limited availability because of her work schedule and she felt that there was more to this problem than just not being able to read as well. The past medical history showed him to be a full-term infant with normal growth and development. Vision and hearing screening at school were reportedly normal. The family history was positive for relatives on both sides of the family who had some school problems but the mother was not sure what they were. Her sister and brother got some “special help” at school, and some paternal relatives struggled to finish school.

    The pertinent physical exam showed a well-appearing male with normal vital signs. Growth parameters were 50-75%. The diagnosis of a healthy male with a possible learning disability was made. The mother was told to contact the school and ask for him to be formally evaluated. In addition, the physician also arranged formal vision and hearing evaluations that eventually were normal. The mother returned with another child for an acute care appointment 2 weeks later. She said that she had gone to the school and they again told her there was nothing more they could do for her son. The pediatrician told the mother that he would draft a letter that the mother could re-write and send to the school. “Sometimes you need to have to ask them in writing,” the pediatrician said. About 1 month later, the pediatrician saw the mother in a clinic hallway and she reported that the educational evaluation was underway because of the letter. The pediatrician was glad to learn this because he was not sure how he could intervene if the letter hadn’t worked. He now realized the next hurdle was to make sure the child actually got educational services if they were needed.

    Discussion
    Health does not exist in the vacuum of the office or hospital visit. Therefore the social needs of the patient and family must also be addressed to promote the health of the individual, family and the community also.
    Legal needs are adverse social conditions with legal remedies that reside in laws, regulations or policies.” Benefit denial is a common example. The patient such as the one above who was denied educational assistance initially had a social need that would have becomes a legal need because access to the system is prescribed by law.

    The first medical-legal partnership in the U.S. was established in Boston, Massachusetts in 1993 serving pediatric families, and since then the programs have expanded to serve more than 200 institutions around the United States. In a recent review of a pediatric medical-legal partnership, the most common legal needs were because of benefits, housing issues and educational rights issues. Many of the reasons families sought help were to ask questions about the legal system such as how to escrow rent or ask for a school evaluation.

    Medical-legal partnerships may also be formed to help alleviate public policy and system burdens – benefit claims, gun control, child safety, benefit claims, etc.

    Learning Point
    Legal issues that affect health include:

    • Income and Insurance
      • Insurance access and benefits
      • Disability benefits
      • Food programs
      • Social security benefits
    • Housing
      • Access to shelter
      • Access to shelter subsidies such as Section 8 program
      • Foreclosure prevention
      • Safe/sanitary housing conditions such as lead or mold abatement
      • Utility access
      • Compliance with regulations including Federal, State and local laws and ordinances – Americans with Disability Act
    • Education and Employment
      • Compliance with regulations including Federal, State and local laws and ordinances – Americans with Disability Act, Individuals with Disability with Education Act
      • Discipline issues
      • Discrimination
    • Legal status
      • Criminal record and juvenile justice system issues
      • Immigration – asylum, Violence Against Education Act
    • Personal and Family Stability
      • Custody, guardianship, divorce foster care, paternity
      • Capacity/competency including mental health and minors
      • Child and elder abuse and neglect
      • Domestic violence
      • Advance directives and end of life care
      • Estate planning
      • Powers of attorney

    Other legal issues for health care providers

    • Consent
    • Professional liability/malpractice – civil, criminal and ethical
    • Personal liability
    • Research – patent, trademark, compliance
    • Running a business – legal compliance and taxation
    • Reportable obligations – whistle blowing, knowledge of laws being broken, criminal investigation

    Questions for Further Discussion
    1. What legal services do you have available to you where you practice?
    2. How are legal services for needy families financed?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Caregivers, Advance Directives, and School Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Zuckerman B, Sandel M, Smith L, Lawton E. Why pediatricians need lawyers to keep children healthy. Pediatrics. 2004 Jul;114(1):224-8.

    Zuckerman B, Sandel M, Lawton E, Morton S. Medical-legal partnerships: transforming health care. Lancet. 2008 Nov 8;372(9650):1615-7.

    Sandel M, Hansen M, Kahn R, Lawton E, Paul E, Parker V, Morton S, Zuckerman B. Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff (Millwood). 2010 Sep;29(9):1697-705.

    Klein MD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children–outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013 Aug;24(3):1063-73.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the Essential Amino Acids and How Much Protein Do I Need?

    Patient Presentation
    A 14-year-old male came to clinic for his health supervision visit. He was a runner and had become more interested in eating healthier to improve his running. “I’m drinking more milk and eating more vegetables lately,” he said. “I’m thinking about eating vegetarian, but I’m not sure that I can get enough protein. I don’t like seeds, nuts, or tofu, so I’m not sure that I can do it,” he explained. The past medical history showed no athletic injuries. The family history was positive for heart disease and stroke in family members > 60 years of age. The review of systems was negative.

    The pertinent physical exam revealed a thin male with height at the 75% percentile and weight at the 25%. Vital signs were normal as was the rest of his physical examination. The diagnosis of a healthy male was made. He was counseled to continue to eat a variety of foods including calcium-rich foods. The pediatrician told him that he still could get enough protein in his diet using a variety of foods if he chose to eat a vegetarian diet. “It’s important to eat a wide variety of foods in your diet and in general as long as you are eating enough calories from good foods, and a combination of foods you probably should get enough protein. Some people try to make the change to eating vegetarian all at once, but others do it in more steps. You also have to consider who is going to buy the food and cook it, so you need to think about the rest of your family too and how they eat. You might want to try to make some changes to your breakfast, lunch and snacks first since you control those foods more. Then maybe try adding in meatless dinner more often,” the pediatrician offered. “You may also find out that you like some nuts or tofu when you cook them differently.”

    Discussion
    Vegetarians have a diet pattern that emphasizes consuming plant foods (i.e. vegetables, grains and nuts) and avoiding flesh food (i.e. red meat, poultry, fish). Some vegetarians include milk and egg products in their diets and would be more accurately described as lacto-ova-vegetarians. Vegans are vegetarians who avoid all animal products including foods such as dairy products, eggs, butter, honey and gelatin.

    One of the most common questions that vegetarian are asked is about how they obtain enough protein from their diets. In general, a mixed diet of a variety of foods with appropriate calories should provide anyone, vegetarian or not, with enough protein. Vegetarians like anyone who is restricting or avoiding certain foods, just need to pay a little more attention to the mixture of foods they are consuming. Vegetarians like everyone need to pay attention to the calories from fat in their foods also because nuts, seeds, some plants such as avocados, eggs, and some dairy products contain a higher amount of fat and calories. They are healthy foods but like any food, these need to be consumed as part of an overall healthy diet. To review what types of foods vegetarians should eat to maintain proper nutrition, click here.

    Learning Point
    Amino acids are categorized as essential and non-essential. Essential amino acids are those which cannot be synthesized by the body and must be obtained from food. These include 9 amino acids: histadine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan and valine. Non-essential amino acids can be synthesized by the body or occur in the normal breakdown of protein.

    Complete proteins are those which contain all the essential amino acids in the proper proportion. Usually these are from animal protein such as meat, poultry, fish, eggs, milk, cheese and yogurt, but also soy and quinoa are complete proteins. Incomplete proteins are those which may contain all the essential amino acids but are low in 1 or more of them. For example grains have lower lysine, isoleucine and threonine and legumes have lower methionine and trptophan. Nuts and seeds are lower in lysine and isoleucine. Proteins from plants, legumes, grains, nuts, seeds and vegetables are usually incomplete proteins. Complete proteins can be made by eating a variety of different foods that “compliment” each other. There’s a reason that people have been mixing beans and rice (i.e. red beans and rice, dal and rice), beans and corn (i.e. tacos, chili beans and cornbread), beans and bread (i.e. hummus on pita bread) for a long time. The complimentary foods do not need to be eaten in the same meal but should be consumed over the day. It is possible to eat enough of an incomplete protein food to get enough amino acids to make a complete protein but most people would not choose to eat 8 large potatoes, 15.5 cups of rice, or almost 13 cups of corn to get enough protein in their diet.

    There is also protein in fruits and vegetables themselves but in much smaller amounts.

    The recommended daily allowance of protein is about ~0.8 grams/kg/day of protein. This is about 45-55 g/day for teens and adults. Total amounts for children obviously is lower. One cup of milk or yogurt is 8 and 11 grams of protein respectively. Three ounces of meat is about 21 grams of protein and 1 cup of dried beans is about 16 grams.

    Most people don’t think about their diets this way, they think about amounts. The USDA recommends 5 ounce equivalents of protein a day for girls and women > age 9 years. For boys or men it ranges from 5-6.5 ounce equivalents depending on age. Boys 9-13 years should have 5 ounce equivalents/day, those boys and men 14-30 years should have 6.5 ounce equivalents/day, those 31-50 years should have 6 ounce equivalents/day, and those men > 51+ years should have 5.5 ounce equivalents/day. An ounce equivalent is 1 ounce of an animal protein such as 1 ounce of lean beef, ham, pork, chicken or fish or 1 egg. Nuts and seeds butters (i.e. peanut butter) are 1 tablespoon = 1 ounce equivalent. Nuts and seeds are 1/2 ounce = 1 ounce equivalent. Beans, peas, and tofu are 1/4 cup of cooked item = 1 ounce equivalent.

    Questions for Further Discussion
    1. What are tofu, tempeh and seitan?
    2. Which types of foods are anti-oxidant rich?

    Related Cases

    To Learn More

    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Vegetarian Diet

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Knutson P. Your Vegan Guide to Foods With Protein. Vegan Coach.
    Available from the Internet at http://www.vegancoach.com/foods-with-protein.html (rev. 2014, cited 8/26/14).

    Savvy Vegetarian. How to Get Enough Protein In Vegetarian\Vegan Diets.
    Available from the Internet at http://www.savvyvegetarian.com/articles/get-enough-protein-veg-diet.php (rev. 2014, cited 8/26/14).

    Centers for Disease Control. Protein.
    Available from the Internet at http://www.cdc.gov/nutrition/everyone/basics/protein.html (rev. 10/4/12, cited 8/26/14).

    Mangels R. Protein in the Vegan Diet. Vegetarian Resource Group.
    http://www.vrg.org/nutrition/protein.php
    (rev. 2014, cited 8/26/14).

    United States Department of Agriculture. What Counts as an Ounce Equivalent in the Protein Foods Group? ChooseMyPlate.gov.
    http://www.choosemyplate.gov/printpages/MyPlateFoodGroups/ProteinFoods/food-groups.protein-foods-counts.pdf

    United States Department of Agriculture. How Much Food from the Protein Foods Group is Needed Daily? ChooseMyPlate.gov.
    http://www.choosemyplate.gov/printpages/MyPlateFoodGroups/ProteinFoods/food-groups.protein-foods-amount.pdf (cited 8/26/14)

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital