How Do You Treat Water for Cryptosporidium?

Patient Presentation
A 16-year-old male came to clinic with several days of diarrhea that he describes as loose and watery and occurred with some urgency. He denied blood in the stool, fevers, chills, nausea, emesis, abdominal cramping or rashes. He denied any significant weight loss and was urinating well. He had been camping with several other teenage boys just before the diarrhea occurred. They had camped on farmland that was used for dairy animals and crops. “We drank the water from the creek but we did boil it,” he said. He said at least one other camper also had diarrhea. The past medical history showed a healthy male with several athletically-related orthopaedics injuries.

The pertinent physical exam showed a well-developed male. His weight was the same as at a recent well-child examination. His abdominal examination was negative. The diagnosis of a diarrheal illness caused by viral, bacterial or protozoan organisms was made. As he was otherwise well and was well-hydrated, no specific treatment was done but continued hydration and good hygiene was advised. The laboratory evaluation of stool cultures for bacteria and parasites were sent because of the illness duration. The state epidemiology laboratory did extended testing because of the history and diagnosed Cryptosporidium. The state epidemiology team followed up with the patient and the contacts but all had improved when contacted.

Discussion
Cryptosporidium is an oocyte-forming coccidian protozoan. It is transmitted through ingestion of contaminated food, water, or contact with infected persons or animals (particularly preweaned calves). It is a common cause of diarrhea from contaminated recreational water supplies including lakes, ponds, streams, and pool and waterpark water. It has been associated with occupational exposures in agricultural settings and veterinary schools. Emergencies where calves or biological samples are involved have caused transmission of Cryptosporium to first responders. Others at risk include young children and those who care for them (i.e. parents, child care professionals), swimmers who swallow contaminated water, those exposed to human feces through sexual contact, and domestic and international travelers. Travelers who drink unfiltered, untreated water are at higher risk. People who are immunocompromised are also at higher risk.

The most common symptom is watery diarrhea that begins about 7-10 days (range 2-26 days) after infection and is self-limited. Excretion can be intermittent and last for weeks. Other symptoms are abdominal cramps, decreased appetite and weight loss, emesis, fever, fatigue, headache and joint pain. Cryptosporidium testing is usually not included in routine ova and parasite testing so specific testing often needs to be requested. Multiple stool samples may be needed because of the intermittent excretion.

Immunocompetent patients are usually not treated, but nitazoxanide can be used for both immunocompetent and immunocompromised patients.

Common causes of diarrhea can be found here.

Learning Point
Recreational water supplies are a common source as the pool chemicals (often halogens such as chlorine and bromine) are ineffective against Cryptosporidium. Even well maintained facilities can have tainted water and small amounts can cause disease. Cryptosporium can lives for days outside the host. It is a very hearty organism and difficult to kill.

Bathers should not use recreational water if they have open cuts, or sores to help prevent transmission. Swallowing water is never recommended. Inadequately treated water should be avoided. This includes ice or water from lakes, streams, ponds, rivers, springs or shallow wells where the water may be unsafe. Water supplies can be appropriately treated for Cryptosporidum by:

  • Using bottled water instead including for personal hygiene and food preparation.
  • Heating the water to a rolling boil and boiling for 1 minute.
  • Using a water filter. This should be with an absolute pore size of 1 micrometer or smaller or use of an NSF Standard 53 or NSF Standard 58 filter for cyst and oocyst reduction. If a filter is used, then the water will still need additional treatment to kill or inactivate viruses and bacteria.
  • Using chlorine dioxide (not the pool chemical) appropriately
  • Using ultraviolet light appropriately

Detailed information regarding water disinfection for travelers can be found here.

Questions for Further Discussion
1. List other infectious diseases transmitted primarily through water.
2. What are the common causes of traveler’s diarrhea and how is it treated?

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: Cryptosporidiosis.

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. Parasites – Cryptosporidium. Available from the Internet at http://www.cdc.gov/parasites/crypto/ (rev. 3/9/11, cited 1/6/15).

American Academy of Pediatrics. Cryptosporidiosis, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2012;296-98.

Centers for Disease Control. Traveler’s Health Cryptosporidiosis. http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/cryptosporidiosis. (rev. 8/1/13, cited 1/6/15)

Webb LM, Tubach SA, Hunt DC. Outbreak of cryptosporidiosis among responders to a rollover of a truck carrying calves – Kansas, April 2013. MMWR Morb Mortal Wkly Rep. 2014 Dec 19;63(50):1185-8.

Author

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

How Good is 5-Fluorouracil to Treat Plantar Warts?

Patient Presentation
A 4-year-old male came to clinic for treatment of plantar warts that had been present for less than a month. His mother had tried salicylic acid inconsistently and wanted cryotherapy. The past medical history showed a healthy male and the review of systems was normal.

The pertinent physical exam a healthy male with normal vital signs and growth parameters. On the ball of the left foot and great toe he had two flat, but cauliflower-like lesions of ~3-4 mm in size that were relatively superficial. The diagnosis of plantar warts was made. The resident was reviewing his treatment plan with his attending and said that he was going to write a prescription for “WartPEEL®” as one of his other attendings liked that medication instead of plain salicylic acid. His current supervisor asked him what was in the medication and a website showed that it was 5-Fluorouracil and salicylic acid in a proprietary formula. The attending asked the resident about if there was any data that 5FU was more efficacious than plain salicylic acid and what was the difference in cost. The resident wasn’t sure so he said he would try to look into this over the next few days.

Discussion
Veruccae plantaris or plantar warts are caused by Human papillomavirus which causes benign epidermal tumors that often have a cauliflower pattern on the foot that may be elevated or flush with the surrounding skin. Lesions may resemble calluses but the normal footprint pattern is disrupted. The lesions often have pinpoint hemorrhages that appear as black dots. In an immunocompetent individual, the lesions usually have spontaneous resolution within 2 years but the infection may spread to create additional lesions. The lesions may also cause pain or discomfort because of their size or location.

Plantar warts are often difficult to treat. Treatments include keratolytics (e.g. salicylic acid (SA) or tricholoacetamic acid), cryotherapy with liquid nitrogen, electrodesiccation, or direct surgical removal. Suffocation by duct tape and plastic have also been used. Immunotherapy with candida, mumps or trichophytin antigens have been used more recently. These are felt to induce a local and distant immunoresponse that destroys the lesions.

5-Fluorouracil (5FU) is an antineoplastic and antimetabolite that inhibits DNA and RNA synthesis which is believed to be the mechanism that stops wart proliferation WartPEEL®. WartPEEL® is a compounded medication available only in certain locations in the United States and is not FDA approved currently.

Learning Point
Warts are difficult to treat. It takes a long time to treat them. Relapse and spread are common. There can be pain and discomfort with each treatment or with no treatment also. Cost and often daily treatments makes the treatment often difficult to comply with.

Placebo cure rates for wart treatment are around 20-40% for many trials and trials often have end points between 3-6 months.

Topical 5FU compared to placebo shows ~50% cure rate for several trials. Topical 5FU/SA compared to placebo shows 46% versus 19% cure rate. Topical 5FU versus occlusion with duct tape showed 85% cure versus 10% after 6 months of treatment.

5FU is also used as an intralesional treatment. Studies have found intralesional 5FU compared to placebo have a cure rate of 64-70% versus 29-35%.

Questions for Further Discussion
1. 5FU is used for what other disease processes?
2. How effective is intralesional candida treatment? Click Here

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: Warts and Human Papillomavirus.

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.

Zschocke I, Hartmann A, Schlöbe A, Cummerow R, Augustin M. Efficacy and benefit of a 5-FU/salicylic acid preparation in the therapy of common and plantar warts–systematic literature review and meta-analysis. J Dtsch Dermatol Ges. 2004 Mar;2(3):187-93. [Abstract only in English]

Salk RS, Grogan KA, Chang TJ. Topical 5% 5-fluorouracil cream in the treatment of plantar warts: a prospective, randomized, and controlled clinical study. J Drugs Dermatol. 2006 May;5(5):418-24.

Kwok CS, Gibbs S, Bennett C, Holland R, Abbott R. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012 Sep 12;9:CD001781.

Author

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

What is the Remission Rate for Antithyroid Drug Treatment for Hyperthyroidism in Children?

Patient Presentation
A 12-year-old female came to clinic for her health maintenance examination. She had no complaints and her mother had no concerns until her daughter was weighed and there was a slower increase in her weight over the year. The patient had normal eating and activity and they denied weight loss. She was sleeping well without night sweats, had normal elimination and was doing well in school. She had a history of being a more anxious child but this was unchanged. The family also denied any skin or hair changes. The past medical history was negative except for some normal acute illnesses. The family history was positive for diabetes, stroke and arthritis. The review of systems was otherwise normal.

The pertinent physical exam showed a well-appearing Asian female with a heart rate of 108 beats/minute, blood pressure of 106/56, respiratory rate of 20 and she was afebrile. Her height was 90% and tracking normally. Her weight had always been at the 95% and was now at the 90%. HEENT revealed very subtle proptosis with the eyelids still covering part of the irises. Her thyroid was diffusely enlarged without palpable nodes and there was no murmur over the organ. She had some shoddy anterior cervical adenopathy. Heart was mildly tachycardic without a murmur. She had normal skin without hair loss or increased perspiration. Neurological examination found a mild tremor of her hands when they were outstretched and she seemed somewhat anxious to the examiner. She also had mild hyperreflexia in all extremities. The laboratory evaluation showed a thyroid stimulating hormone of < 0.1 microU/mL (normal 0.5-4.7 microU/mL), and a free T4 of 3.9 ng/dL (normal 0.8-2.7 ng/dL).

The diagnosis of hyperthyroidism with thyrotoxicosis was made and pediatric endocrinology was consulted by telephone. An appointment for evaluation was made for 2 days later. The radiologic evaluation of a thyroid ultrasound found a mildly diffusely enlarged organ without nodules. Additional laboratory testing was positive for TSH receptor antibodies consistent with Grave’s disease. She began treatment with the antithyroid drug methimazole.

Discussion

The thyroid gland secrets two hormones – T4 which is a prohormone and T3 which is the biologically active hormone. Receptors for T3 are found in nearly all body tissues. T3 regulates metabolism and energy production. Organs most affected are the heart, liver and central nervous system as well as growth of the fetus and child. Hyperthyroidism is common with a prevalence rate of about 1-2% for women and 0.2% for men. The most common cause of thyrotoxicosis is Grave’s disease where autoantibodies to thyroid stimulating hormone (TSH) exist. These autoantibodies attach to thyroid tissue TSH receptors and increase the production of T4 and T3. Grave’s disease often co-occurs with other autoimmune diseases such as diabetes, Hashimoto’s thyroiditis, rheumatoid arthritis and also with Turner’s, Down’s and Di George syndromes. Children only account for about 1-2% of all patients with Grave’s disease.

Signs and symptoms of thyrotoxicosis include:

  • Cardiovascular – tachycardia, palpitations, shortness of breath, arrhythmias, hypertension and high output failure
  • Eyes – soreness and irritation, staring, eyelid retraction, periorbital edema, ophthalmoplegia, conjunctival injection
  • Gastrointestinal – weight loss, increased appetite
  • Genital system – Oligomenorrhea, decreased fertility, reduced libido in men
  • Musculoskeletal – muscle weakness or tremor, muscle wasting
  • Neck – neck swelling
  • Nervous system – hyperactivity, anxiety, concentration problems, fatigue and nervousness, hyperreflexia
  • Skin and Hair – heat intolerance, increased perspiration, warm, moist skin, thinning or hair loss

Treatment options for thyrotoxicosis includes:

  • Antithyroid drugs (ATD) – The most common drugs used are carbimazole and its active metabolite methimazole (MMI) and propylthiouracil. Propylthiouracil is usually not used because of the risk of severe hepatitis.
    MMI is the most common first line drug used and is taken orally daily. Side effects include hives, rashes, gastrointestinal problems and arthritis.
    The goal is to create a euthyroidism condition which then stops the autoimmune response and the thyrotoxicosis. This is defined as the clinical remission.

  • Radioactive iodine (RAI) – it is often used as a more radical treatment if clinical remission cannot be obtained or sustained with ATDs. It may be used as a first line treatment for patients with a large goiter or opthalmopathy.
    A single dose if often used, but the patient may need additional treatments. It is not used in young children, or pregnant or lactating mothers because of the potential risk of neoplasia.

  • Surgery – total or near total thyroidectomy is the most common surgery. RAI may be needed if hyperthyroidism continues after surgery. Surgery causes hypothyroidism and the need for lifelong replacement thyroid medication.

Learning Point
Only about 30% of children achieve clinical remission with ATD treatment, whereas 60-70% of adults achieve remission.
Longer term ATD may be necessary to achieve and keep children in clinical remission. If remission cannot be achieved or sustained, then other treatment is necessary.

Favorable predictors of Grave’s disease remission are older age group, presence of other autoimmune conditions and duration of ATD treatment more than 2 years.
Unfavorable predictors are younger age, large goiter, non-Caucasian race, biochemical severity and ATD medication non-compliance.

Questions for Further Discussion
1. How is Hashimoto’s thyroiditis different from Grave’s Disease?
2. What causes thyrotoxicosis?

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: Hyperthyroidism

.

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.

Franklyn JA, Boelaert K. Thyrotoxicosis. Lancet. 2012 Mar 24;379(9821):1155-66.

Leger J, Carel JC. Hyperthyroidism in childhood: causes, when and how to treat. J Clin Res Pediatr Endocrinol. 2013;5 Suppl 1:50-6.

Leger J, Kaguelidou F, Alberti C, Carel JC. Graves’ disease in children. Best Pract Res Clin Endocrinol Metab. 2014 Mar;28(2):233-43.

Author

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

What Are Considerations for a Dancer to Begin Pointe Training?

Patient Presentation
During a discussion among several pediatricians about readiness for various sports training, one pediatrician asked what her colleagues did for young girls who wanted to start ballet dancing on pointe. There were a few general comments but nothing substantial except one person said that she thought there was a recent paper about the topic. Through a literature search, the pediatrician found a paper and then shared the information with her colleagues.

Discussion
Ballet dancing originated in Italy and was patronized by Queen Catherine de Médici of France who began the first ballet school in 1581. King Louis XIV of France was a major patron as he founded the Académie Royale de Danse in 1661. The Sun King was a performing dancer himself. The first documentation of a dancer performing en pointe (ie on pointe or on the tips of the toes) was in 1832 by Marie Talioni performing in La Sylphide.

Dancers are highly trained athletes and when dancing on pointe have the special appeal of appearing to effortlessly defy gravity. Ballet dancing shoes are slippers (made of soft leather, canvas, or satin, that has flexible, thin usually leather soles that that hug the foot), demi-pointe (similar to pointe shoes except for a smaller toe box and no shank in the arch, used more in Europe than United States) and pointe shoes. Pointe shoes have a toe box made of layers of paper, fabric and glue with a squared off end on the toe (i.e. the platform) that the dancer stands on and which provides the majority of the support. The shank is usually made of leather and supports the arch. Fabric (usually satin) surrounds these main pieces and the shoe is attached to the foot by elastic near the ankle and satin ribbons. A professional ballerina once described it to the author as “dancing in a Dixie® cup”. Pointe shoes are highly specialized equipment that needs a trained specialist to properly fit. The fit is extremely important for long-term injury prevention.

When dancing in ballet slippers, the relevé (elevated) foot position places the pressure on the metatarsals at 4x body weight. In demi-pointe or pointe shoes, the pressure is on the toes at 12 times body weight. The “ideal” foot is the “Giselle” foot where the first 3 toes are of relatively the same length allowing for distribution of the force across a greater area. Dancers with different anatomy still can be successful though. Dancing on pointe requires complete plantarflexion of the foot and ankle to 90° or more and is stabilized as the ankle “locks” into position with the subtalus locking between the tibia and calcaneus.

The change from dancing on the metatarsal heads to dancing on the toes seems like it should increase the likelihood of injuries but studies have not shown this. Specifically one study which looked at recreational (non-professional but serious) dancers before pointe shoes and after pointe shoe use did not find an increase in the likelihood of injuries during the past month or past 3 years. Longer term data was not evaluated. Also no studies have found that dancing on pointe before growth plate closure is linked to growth plate arrest, therefore radiographs are unnecessary to use as a factor for determining pointe readiness. Also the growth plates in these bones do not close until 18-20 years well after most dancers are already successfully dancing on pointe.

The quality of the preparatory training is paramount and experienced, ballet-specific instructors are important for preparation, decision making for placement into pointe shoes and training dancers using them. European ballets schools tend to be more rigorous with formalized systems of training and qualified instructors. This is not always true in the United States where dance studios may provide instruction in many different dance types and may not have instructors with specific training as ballet instructors. Studios can be placed under pressure to place dancers into pointe shoes because of the psychological aspirations of the dancer and family, and because of the financial pressures to do so.
As with any athletic activity, training and coaching under the direction of professional dancers with ballet-specific training is the most appropriate for dancers going on pointe.

Learning Point
There is no specific testing that can determine when a dancer can successfully transition to on pointe. One study found that 3 functional tests that help evaluate strength, flexability, alignment, postural control and balance correlated with teacher subjective rating for on pointe dancing readiness. These 3 are:

  • Airplane test – The dancer stands on one leg. The trunk is bent forward while the non-weight bearing leg is elevated behind them. The arms are extended in front creating the look of an airplane flying, or the letter “T” from the side or a Warrior III yoga pose.
    The arms are lowered toward the ground, and the weight bearing leg is bent or folded in a controlled manner (i.e. plié) (<a href="View images here)

  • Sauté test – The dancer stands in a neutral pelvis, upright stable trunk position with arms at the side. The knees are bent and the dancer does a short jump into the air landing with control and a appropriate bending on the knees to absorb the shock. (<a href="View video here)
  • Topple test – a pirouette or turn is performed on one leg. The non-weight bearing leg’s hip is abducted and flexed with the foot aligned next to the weight being leg’s knee. The dancer should be able to do this in the relevé (elevated) foot position.(<a href="View video here“)

The great ballet choreographer George Balanchine once said that it took 4 or more years of serious training before a dancer was ready and with serious training starting around 7-8 years, this would be around 11-12 years or more.

A 2009 study ended with these considerations for pointe readiness. “A dancer should have adequate mental maturity and physical capability to begin dancing on pointe, rather than requiring a specific age or number of years. The dancer should have adequate flexibility in the foot and ankle complex to achieve full pointe, sufficient training to achieve proper placement, strength to achieve postural control and balance, proprioception, alignment, technique, mastery of movement, the ability to learn and perform choreography, and the ability to listen to apply corrections.” These ideas seem appropriate for any athlete including dancers.

Questions for Further Discussion
1. What resources do you have available locally to evaluate dancers for on pointe readiness?
2. What history questions should be gathered to evaluate dancers for on pointe readiness?

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: Exercise and Physical Fitness.

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.

Nunes NM, Haddad JJ, Bartlett DJ, Obright KD. Musculoskeletal injuries among young, recreational, female dancers before and after dancing in pointe shoes. Pediatr Phys Ther. 2002 Summer;14(2):100-6.

Shah S. Determining a young dancer’s readiness for dancing on pointe. Curr Sports Med Rep. 2009 Nov-Dec;8(6):295-9.

Richardson M, Liederbach M, Sandow E. Functional criteria for assessing pointe-readiness. J Dance Med Sci. 2010;14(3):82-8.

Pearson SJ, Whitaker AF. Footwear in classical ballet: a study of pressure distribution and related foot injury in the adolescent dancer. J Dance Med Sci. 2012;16(2):51-6.

Author

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