What Are the Indications for Use of Acyclovir and Post-Varicella Immunization in a Healthy Patient?

Patient Presentation
A 14-year-old female came to clinic with a low-grade fever and rash. The fever began 2 days previous and the rash was noticed on the trunk last evening.
She lived in a group home because of severe mental retardation and mild cerebral palsy.
Her caretaker said that the rash was on the trunk and was spreading with more lesions appearing since the prior evening.
The rash also appeared pruritic because she was picking at her shirt.
She had some decrease in her appetite but was drinking well. Others at the group home had upper respiratory infections recently.
She had no recent travel, new soaps, lotions, or different outside experiences where she could contact different plants. She was current on all her vaccinations.
The review of systems was otherwise normal.
The pertinent physical exam showed she had a temperature of 100.5° F, but the rest of her vital signs were normal.
Her mucus membranes were moist, and she had minor clear rhinorrhea. Lungs were clear and heart was normal.
The skin lesions were vesicular with an erythematous base. There were ~15 lesions but this was increased from ~ 5 lesions the night before. None of the lesions were crusted.
Neurologically, she was non-verbal but could follow simple directions and was relatively cooperative. She had repetitive rocking motions and had increased tone in all extremities.
The diagnosis of varicella was made. Using the American Academy of Pediatrics recommendations, the patient was given oral acyclovir as she was within 72 hours of the rash onset, was at increased risk for severe varicella because of her age (> 12 years) and also because she was in a group home setting where secondary cases may be more severe.
Additionally, the group home and public health was contacted so that the other residents and staff members could receive post-exposure varicella vaccination and/or varicella immunoglobulin. Public health was also following up on her school contacts for the same reasons.
The physician recommended isolation of the patient in her room until the lesions were crusted. He also discussed comfort measures that could be taken, when the patient could return to school, and signs and symptoms that indicate to call or return to the clinic.

Discussion
Varicella zoster virus is a DNA virus in the herpes family.
It is transmitted by respiratory secretions or direct contact with skin lesions with an usual incubation period of 10-21 days after contact.
Patients are contagious 1-2 days before the rash until the lesions are crusted over.
There usually is a prodrome of fever, malaise, headache and upper respiratory symptoms.
Crops of pruritic lesions occur generally beginning on the trunk and then spreading to face and extremities.
The lesions are described as “a dewdrop on a rose petal” for the vesicular lesion on an erythematous base, but the lesions often occur in various stages from papular, vesicular, pustular and crusted.
Mucous membranes can be involved also.
The main complications in immunocompetent people are suprainfection and scarring of the skin.
However, especially in immunocompromised patients, pneumonia, encephalitis, myelitis, meningoencephalitis, and acute cerebellar ataxia can occur.
Case fatality in the general population is ~7/100,000 or 100-150 deaths/year in the U.S. Hospitalizations occur in ~10,500 people/year because of varicella.
Varicella, especially in the first 20 weeks of pregnancy, can lead to multiple congenital abnormalities. Perinatal varicella (defined as 5 days before to 2 days after delivery) puts the neonate at risk for disseminated neonatal varicella because the virus crosses the placenta without time for antibody to pass transplacentally.
Vaccination decreases the incidence of the disease and if the disease still does occur (which happens in 15-20% of patients after 1 vaccine dose), the disease is modified with fewer lesions, faster resolution and fewer complications.
In the U.S., 2 doses of vaccine are recommended protect the 10-30% of children who do not receive protection from the first dose, not because of waning immunity.

Learning Point
For healthy, immunocompetent individuals with varicella, supportive treatment is recommended; oral acyclovir is not recommended.

Oral acyclovir should be considered because of the increased risk of moderate or severe disease in otherwise healthy patients who are > 12 years of age, have cutaneous or pulmonary chronic problems, are on long-term salicylate therapy and people receiving even short courses of corticosteroids (both oral and aerosolized).

Oral acyclovir can give a modest decrease in symptoms and if used it should be begun as soon as possible as viral replication is stopped by 72 hours after the rash.

For susceptible individuals (susceptible meaning never had chickenpox, or not having two vaccines)
who are otherwise healthy and > 12 months of age, post-exposure vaccination with varicella vaccine within 72 hours and possibly up to 120 hours, may prevent of modify the disease and should be considered. Post-exposure vaccination may not prevent all disease.

Immunocompromised individuals are treated much more aggressively including possible hospitalization, administration of intravenous antivirals, and possible administration of varicella immunoglobulin or intravenous immunoglobulin.

In the case above, many of the group home residents were considered at risk because of their age, they had underlying health problems, and were living in a group setting where the risk of secondary cases and complications are higher.
Additionally, many residents and caretakers in the home hadn’t received their second dose of varicella vaccination because the recommendation for 2 doses of vaccinewas changed relatively recently (2006) and there were ongoing vaccine shortages.

Remember that salicyclates should be stopped if a child is exposed or has varicella disease. Acetaminophen is recommended instead.

Questions for Further Discussion
1. If this was varicella zoster, how would the treatment recommendations change?
2. How is neonatal varicella treated?
3. What are the definitions of evidence of immunity to varicella?

Related Cases

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

Information prescriptions for patients can be found at MedlinePlus for this topic: Chickenpox
and at Pediatric Common Questions, Quick Answers for this topic: Chickenpox

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

To view images related to this topic check Google Images.

American Academy of Pediatrics. Varicella-Zoster Infections, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;711-725.

Centers for Disease Control. Varicella Disease Questions & Answers.
Available from the Internet at http://www.cdc.gov/vaccines/vpd-vac/varicella/dis-faqs-gen.htm (rev. 5/10/2007, cited 9/10/2007).

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.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    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.

  • 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.

  • Interpersonal and Communication Skills

    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    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

    Date
    October 30, 2007

  • What Causes Hallucinations?

    Patient Presentation
    A 11-year-old male with known oppositional defiant disorder and attention deficit disorder came to the emergency room about 30 minutes after taking his regular medication when he began to act funny.
    He began to complain of seeing double and was more irritated. He also was saying things that didn’t make sense. The parents called emergency services who transported him to the emergency room.
    During the ambulance ride he was somewhat agitated and kept saying that he was seeing “yellow monkeys” jumping on the walls.
    In the emergency room, he doesn’t remember the ride in the ambulance, but was alert, able to answer questions and wasn’t seeing monkeys.
    Recently he has been working on increasing his responsibility for his own medications. He said that he took his Concerta® and Risperdal® as he usually does, which is that he pours out the medication on to the cap and then takes them directly from the cap into his mouth. One of his parents supervises this but he pours the medication out.
    He says that he took three of his Risperdal tablets instead of one.
    The review of systems was negative.
    The pertinent physical exam showed a tired appearing male whose vital signs were normal including a heart rate of 94 beats per minute, and blood pressure of 106/65 mm Hg.
    The rest of his examination was normal.
    His mental status examination showed a cooperative, appropriately conversant male who was oriented to place, person, time and situation.
    The diagnosis of an accidental Risperdal ingestion was made. A total dose of 9 mg of Risperdal® was calculated by history but the pill bottle was not available.
    The work-up included a normal electrocardiogram, serum chemistries and drug screen which eventually showed no other medications than those prescribed.
    The patient’s clinical course included him being admitted for observation on cardiac monitors because of the risk of long QT syndrome or other arrhythmia. The National Poison Control Center was also contacted to confirm that other treatment was not warranted.
    He had no events over the night and was discharged home the next day. The family agreed to recheck the number of pills he dispensed prior to him taking them.

    Discussion
    Poisonings are unfortunately common occurrences in childhood. Often poisonings occur in toddlers or preschoolers who are curious about something in their environment and consume it. Household products, plants or medications are often ingested.
    Fortunately ~98% of ingestions in this age group are minor in severity. The most common fatal poisoning in this age group is due to iron.

    Adolescent poisoning or overdoses most often occur because of recreational use of medications or suicide attempts. Adolescents are more likely to ingest a large amount of a single substance or to ingest multiple substances.
    Acetaminophen is the most common substance ingested but tricyclic antidepressants are the most likely substance to cause death. Oral ingestions are the most common route, but also dermal, inhalation, injection and ocular routes are used.

    Treatment for poisonings depends on many factors including the substance(s) ingested, route of ingestion, amount taken, age, and other medical condition. Decontamination by removing as much of the substance as possible (i.e. removing clothing, gastric lavage), using an antidote if available (i.e. methylene blue for acetaminophen ingestions), and upportive measures and monitoring until the toxic effects of the substance have worn off (i.e. intubation, cardiac monitoring, etc.) are mainstays of treatment.

    Learning Point
    Hallucinations are beliefs or perceptions about sensory inputs that are not present. Visual hallucinations are more common than auditory hallucinations.
    Illusions are different in that they are misperceptions about sensory inputs that are present.
    Delusions are wrong beliefs or thoughts that continue to be held even when contradictory evidence is presented or can be logically reasoned.
    Delirium is an activated mental state which may include fearfulness, disorientation, irritability and sensory misperception including hallucinations.
    This patient presented had delirium and visual hallucinations.

    Common causes of hallucinations include:

    • Carbon monoxide poisoning
    • Porphyria, acute intermittent
    • Temporal lobe abnormalities – epilepsy, viral infections such as Epstein-Barr virus
    • Schizophrenia
    • Drugs
      • Primary of abuse
        • Cannibis (marijuana)
        • LSD (lysergic acid diethylamide)
        • Methylenedioxymethamphetamine (Ecstasy or MDMA)
        • Phencyclidine (PCP or angle dust)
      • Occurring naturally
        • Mescaline – from peyote cactus
        • Psilocybin – from mushrooms
      • Prescription for treatment of other causes (either during initiation, withdrawal, or accidental overdose)
        • Dissociative anesthetics
        • Tricyclic antidepressants
        • Psychotropic medications

    Questions for Further Discussion
    1. What are indications for a psychiatry or pharmacology consultation?
    2. What are other commonly ingested drugs of abuse and how do these toxidromes present?
    3. What is the telephone number for the national poison control hotline?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Psychotic Disorders and Poisoning
    and at Pediatric Common Questions, Quick Answers for this topic: How to Prevent Poisoning.

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

    To view images related to this topic check Google Images.

    Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:437-441.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1998:221-222.

    Taylor Da, Ashwal S. Impairment of Consciousness and Coma. In Pediatric Neurology Principles and Practice. Mosby, St. Louis, Mo. 3rd Edit. 1999:861.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:356,376.

    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.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    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.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.

  • 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

    Date
    October 22, 2007

  • What Causes Heart Failure?

    Patient Presentation
    A 3-year-old female was referred to the emergency room for further evaluation after her local physician noted hepatomegaly to 4 centimeters below the costal margin and tachycardia.
    She was previously well but complained of fatigue for ~10 days and generalized, achy abdominal pain that was increasing over the last few days.
    The pain was fairly constant but intensity itsdid wax and wane. She lost her appetite about 3 days before and was eating and drinking less.
    Her urine was darker and her stools had normal coloration without blood.
    She was very tired at the end of the day and was taking extra naps. She was having problems with frequent wakening because of coughing.
    The past medical history was negative.
    The family history revealed an uncle with some type of inflammatory bowel disease, and distant relatives with cancer.
    The review of systems showed that she had an upper respiratory infection about 3 weeks ago and that she had no vomiting, diarrhea, dysuria, fever, or rashes.
    She did have a slight cough.
    She and her parents denied any weight change or dependent area edema.
    The pertinent physical exam showed a very tired, pale appearing preschool female. Her vital signs were heart rate ~200 beats/minute, blood pressure = 70/46 mm Hg, respiratory rate = 50, and she was afebrile. HEENT examination was negative. Heart was tachycardic without an obvious murmur. Heart sounds were slightly decreased.
    Pulses in upper and lower extremities were equal but seemed thready. Lungs had rales at the bases. Abdomen had normal bowel sounds with the liver enlarged 4 centimeters below the costal margin. It was uniform in texture and non-tender.
    She had no splenomegaly. Her abdomen was tympanitic without a distinct fluid wave. Genitourinary examination was Tanner 1. She had edema of her feet to the ankle.
    Neurological examination was normal.
    The work-up included an electrocardiogram with a heart rate of ~200-210 beats per minute with morphology consistent with the diagnosis of supraventricular tachycardia.
    She was transferred to the intensive care unit and ice applied to her face 3 times was attempted to convert her to sinus rhythm, but she had only transient heart rate slowing.
    She was given adenosine which decreased her heart rate again temporarily. Concurrently an echocardiogram showed depressed left ventricular function with an ejection fraction of 31% (normal >55%) and shortening fraction of 18% (normal >27%).
    She was given two intravenous boluses of amiodarone for the purpose of cardioversion and then was begun on an infusion that controled the tachycardia.
    The patient had an endomyocardial biopsy (for possible myocarditis which eventually was negative) and electrophysiological studies which showed an arrhythmogenic, ectopic focus in her right atrial appendage causing the supraventricular tachycardia.
    She had cryothermal ablation and afterwards her heart rate ranged between 80 -120 beats per minute with a sinus rhythm.
    Her post-ablation echocardiogram showed improving heart function after the procedure. She was discharged on day 10 on digoxin, captopril, furosemide and propranolol and with much improved clinical signs of heart failure.
    The patient’s clinical course found her to be improving one week later. Over the next 3 months she slowly had her medications weaned.
    At follow-up, one year later, she has had no recurrences and is doing well in preschool and activities.

    Discussion
    Sinus tachycardia is one of the most common arrhythmias. It is a normal sinus rhythm but the heart rate is > 95th percentile for age and usually is less than 220 beats/minute in children and 200 beats/minutes in young adults. It is frequently encountered in children who are febrile or anxious or taking certain drugs such as beta-agonists or theophylline. Sinus tachycardia can be more ominous in cases of anemia, hypovolemia, sepsis, heart failure, pulmonary embolus, or myocardial disease.

    Supraventricular tachycardia (SVT) is defined as a run of 3 or more premature supraventricular beats not originating from the sinoatrial node, often seen as abnormal or absent P waves. The rate can vary, but is usually above 220 beats/minute. It is also usually associated with a narrow QRS complex and can be intermittent or sustained in duration. Most often SVT is associated with an accessory pathway of cardiac muscle which provides a “re-entry” circuit for the arrhythmia, but it may also be caused by an ectopic focus of tissue with its own automaticity as in this case. Initial treatment is by using vagal maneuvers such as ice to the face or Valsalva maneuvers. Adenosine can also be used if vagal maneuvers are unsuccessful and will convert most SVT to normal rhythm if due to a re-entry circuit. If the patient is unstable, electrical cardioversion can be tried. It can sometimes be difficult to determine if the rhythm is sinus tachycardia ro SVT, especially if the rates are > 200 beats/minute.

    Learning Point
    Congestive heart failure occurs when the heart cannot pump enough blood to meet the body’s needs, cannot handle venous return adequately or a combination of both, despite compensatory mechanisms.
    Clinically, congestive heart failure presents with poor feeding, inadequate weight gain, sweating or shortness of breath especially with feeding or other activities, edema of the eyes, feet or hands, or increased fatigue.
    Physical examination may reveal poor pulses and capillary refill, cold skin, tachycardia, abnormal rhythms, dyspnea, orthopnea, wheezing or rales, hepatomegaly without splenomegaly, edema of dependent areas, and distended neck veins.
    Treatment for congestive heart failure is with inotropic support (e.g. dopamine, digoxin), alleviating venous congestion (e.g. diuretics), vasodilatation (i.e. ACE inhibitors) and beta-blockade (e.g. propanolol). Patients also may need other supportive treatment such as mechanical ventilation, supplemental oxygen, bed rest, positioning, and mechanical circulatory supports.
    Treatment for identifiable underlying causes such as the SVT in this patient, need to be instituted.

    The most common reason for heart failure in children is volume overload secondary to a left-to-right shunt.

    Causes of heart failure include:

    • Acquired
      • Arrhythmias – complete heart block, SVT
      • Arteriovenous malformations, high output
      • Bronchopulmonary dysplasia
      • Acute cor pulmonale secondary to airway obstruction – large tonsils and adenoids, cystic fibrosis
      • Cardiomyopathy, idiopathic dilated
      • Drug side effects – doxorubicin (or other anthracyclines), substance abuse
      • Endocardial fibroelastosis
      • Endocrine – adrenal diseases, hyperthyroidism, hypothyroidism
      • Infection – acute rheumatic carditis and/or valve disease, HIV, Lyme disease, sepsis, viral myocarditis
      • Metabolic abnormalities – acidosis, anemia, hypoxia, hypocalcemia, hypoglycemia
      • Renal disease – failure, hypertension
      • Vasculitis – collagen vascular disease, Kawasaki disease
    • Congenital
      • Arterio-venous canal
      • Large atrial septal defect
      • Coarctation of the aorta
      • Genetic diseases – Friedreich’s ataxia, glycogen storage disease, Hunter-Hurler syndrome, Marfan syndrome, muscular dystrophy, Noonan syndrome
      • Hypertrophic left heart syndrome
      • Large patent ductus arteriosus
      • Persistent pulmonary hypertension
      • Totally anomalous pulmonary venous return
      • Truncus arteriosus
      • Single ventricle
      • Large ventricular septal defect
      • Valvular problems – critical aortic stenosis, critical pulmonary stenosis, pulmonary insufficiency, tricuspid insufficiency

    Questions for Further Discussion
    1. What are indications for intubation and ventilation for a patient with an arrhythmia or heart failure?
    2. What are the different types of cardioversion and what are their indications?
    3. What are common causes of fatigue in a child?
    4. What are indications for treatment with mechanical devices such as ventricular assist devices, extracorporal membrane oxygenation?
    5. What are the most common causes of SVT and how do their mechanisms differ?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Arrhythmias and Heart Failure
    and at Pediatric Common Questions, Quick Answers for this topic: Heart Murmurs and Arrhythmias.

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

    To view images related to this topic check Google Images.

    Park MY. Pediatric Cardiology for Practitioners. 3rd Edit. Mosby, St. Louis, MO. 1996:401-403.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1869-1877.

    Robertson J, Shilkofski N. The Harriet Lane Handbook. 17th. Edit. Mosby Publications: St. Louis. 2005:177-179.

    Odland HH, Thaulow EM. Heart Failure Therapy in Children.
    Expert Rev Cardiovasc Ther. 2006;4(1):33-40.

    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.
    6. Information technology to support patient care decisions and patient education is used.
    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.
    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.

  • Systems Based Practice

    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    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

    Nicholas Von Bergan, M.D.
    Pediatric Cardiology Fellow, University of Iowa Children’s Hospital

    Date
    October 15, 2007

  • What is the Differential Diagnosis of a Neck Mass?

    Patient Presentation
    A 2-year-old female came to clinic with sudden onset of left-sided neck swelling.
    She had been well the previous evening and woke up with the swelling.
    She had no pain, fever, skin rashes, mental status changes, night sweats or weight loss. She was eating and breathing normally.
    She did have some rhinorrhea for the past 3 days. Her mother said that the swelling had not seemed reddened or warm to her.
    The past medical history showed a healthy female with 2 previous ear infections and she was up to date on her immunizations including having one Measles-Mumps-Rubella vaccine.
    The family history revealed stroke and renal abnormalities.
    The review of systems was normal.
    The pertinent physical exam showed temperature of 36.2° C, pulse = 108 beats/minute and respiratory rate = 32 breaths/minute.
    Growth parameters were in the 10-75% with no weight loss and she was not distressed.
    HEENT showed normal ears and throat. She had obvious left submandibular, subauricular, and anterior auricular swelling that covered the angle of the mandible. The swelling was confluent, firm but not hard, non-tender, non-erythematous and not warm.
    She had full range of motion in the temporomandibular joint and neck.
    There was no fluid seen from the salivary ducts when they were milked. There was no pain or swelling of the dental tissues.
    There were shoddy anterior and posterior cervical lymph nodes. There were no supraclavicular nodes palpable.
    Skin was normal with no rashes and no dimpling notable on the neck. There was no thyroid enlargement. Lung examination was negative.
    The diagnosis of parotitis/sialadenitis was made. Because she was immunized and there were several enteroviruses in the community, one of these viruses was suspected as the cause.
    The laboratory evaluation included mumps titres which eventually were negative.
    The patient’s clinical course showed she had a low grade fever and developed a rash on her palms and soles later the first day, but she had slow resolution of all symptoms over 7 days.

    Discussion
    Sialadenitis is swelling of the salivary glands, which may include the parotid gland. If the parotid gland is involved then it is called parotitis.

    Parotitis can be caused by:

    • Infections
      • Viruses – primary mumps but also cytomegalovirus, coxsackievirus and other enteroviruses, lymphocytic choriomeningitis virus, human immunodeficiency virus, influenza A, and parainfluenza virus 1 and 3
      • Mycobacterium, non-tuberculous
      • Staphylococcus aureus
    • Drug reaction – iodides, phenylbutazone, thiouracil
    • Metabolic disorders – diabetes, cirrhosis, malnutrition
    • Pneumoparotitis – i.e. air is forced into the salivary ductal system, e.g. instrument playing, ventilation during anesthesia
    • Psychiatric – bulemia, pica
    • Salivary duct calculi – i.e. sialolithiasis
    • Starch ingestion

    Mumps belongs to the Paramyxoviridae family of RNA viruses. It is spread by respiratory secretions and humans are the only known natural host. Because of vaccination there are < 300 cases/year in the U.S. with most being in people > 14 years of age. In immunized children, mumps is not a common cause of parotitis.
    Incubation is from 16-18 days but cases may occur from 12-25 days after exposure. Maximum communicability is from 1-2 days before parotid swelling to 5 day after onset. About 1/3 of infections do not have clinically apparent salivary gland swelling but only have respiratory symptoms.

    Learning Point
    The differential diagnosis of a neck mass includes:

    • Infectious lymphadenitis – most common cause of a neck mass. Some agents include:
      • Viral
        • Adenovirus
        • Coxsackie
        • Epstein Barr virus
        • Influenza
        • Parainfluenza
        • Other respiratory viruses
      • Bacterial
        • Staphlococcus aureus
        • Streptococcus, group A beta-hemolytic
        • Bartonella henselae
        • Haemophilus influenzae
        • Anaerobic bacteria if dental infection is suspected
        • Toxoplasmosis – if single lymph nodes
      • Fungal
        • Actinomycosis
        • Histoplasmosis
      • Tuberculous
        • Mycobacterium tuberculi
        • Atypical mycobacterium
      • Unknown
        • Kawasaki disease
    • Noninfectious inflammatory masses
      • Sarcoid
      • Sialadenitis
    • Congenital
      • Branchial anomalies – lie along the anterior border of the sternocleidomastoid muscle or deep to it, occurring anywhere between the external auditory canal and the clavicle.
        There can be cysts, sinuses or fistulas. Remember branchial clefts are external (mainly ectodermal) and branchial pouches are internal (mainly endodermal) in location.

        • First branchial cleft abnormalities – found superior to the hyoid bone
          First cleft and pouch forms ear

        • Second branchial cleft abnormalities – 2/3 of the way down the sternocleidomastoid muscle – most common branchial cleft abnormality
          Second, third, and fourth clefts are obliterated
          Second pouch forms tonsil

        • Third branchial cleft abnormalities – 2/3 of the way down the sternocleidomastoid muscle
          Third pouch forms the parathyroid gland and thymus

        • Fourth branchial cleft abnormalities – are not seen
          Fourth pouch forms parathyroid gland
      • Dermoid cysts
      • Encephalocoeles
      • Laryngocoeles
      • Parathyroid cysts
      • Thyroglossal duct cysts, sinuses and fistulas
      • Thymic cysts
    • Vascular lesions
      • Hemangiomas
      • Hemangiolymphangiomas
      • Lymphangiomas including cystic hygromas
    • Tumor
      • Benign – teratoma, desmoid tumor, myositis ossificans, shortening of the sternocleidomastoid muscle
      • Malignant – histiocytosis, lymphoma, neuroblastoma, schwannomas, rhabdomyosarcoma

    Questions for Further Discussion
    1. Categorize neck masses by location, i.e. lateral, anterior, posterior?
    2. When should lymphadenopathy be evaluated?
    3. What types of imaging modalities are available to evaluate neck masses and what are their indications?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for this topic: Neck Injuries and Disorders
    and Salivary Gland Disorders.

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

    To view images related to this topic check Google Images.

    Sadler TW, Langman’s Medical Embryology. Williams and Wilkins, Baltimore, MD. 5th edit. 1985;281-294.

    American Academy of Pediatrics. Mumps, In Pickering LD, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2006;464-468.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1279-1281.

    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.

  • 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

    Date
    October 8, 2007