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The Dengue Dance?

Patient Presentation
“My friend Usha, finally came back to school today,” began the dinner conversation with a pediatrician’s daughter.
“She went to India to visit her family, and got some disease. It made her really sick with a fever and they had to stay with their family until she got better,” the girl went on.
“Do you know what it was?” asked the pediatrician.
“I don’t know but she had a bad fever and it sounds like the name of a dance,” she replied.
The pediatrician offered, “We’ll it could be many things. Was it malaria?”
“No that doesn’t sound right,” she answered.
“Maybe Dengue?” said the pediatrician.
“That sounds right! It sounds funny to me like some type of music or dance,” the daughter said.
“I think you are thinking of Merengue,” she parleyed.
“Yeah. Merengue – Dengue, they sound like something you should move to,” the daughter laughed.
“Merengue is great Caribbean music, but Dengue could be really bad. I’m really glad that Usha is much better,” the pediatrician commented.

Discussion
Dengue is an important arboviral infection that affects about 40% of the world population. It is found mainly in topical and subtropical areas of the world mainly in developing countries but it range is spreading including the United States. A review of common arboviruses can be found here. It is a flaviavirus with 4 distinct serotypes named DENV-1 through DENV-4 and is spread by A. aegypti a day biting mosquito. Infection with one serotype confers immunity to that serotype but not the others. It does offer some protection for cross-infection but this only lasts a few months. Incubation period is 3-14 days with an average of 7 after exposure.

A primary infection is usually benign. A second infection with another serotype or multiple infections with different serotypes can cause severe infections.
Dengue fever (DF) presents with skin flushing and abrupt high fever (often biphasic 39.4-40.5C) but could also usually be lower that lasts for 5-7 days. Myalgia and pain especially headache or retroorbital pain is generally constant but remits in a few days. Anorexia, nausea, emesis or abdominal pain occur. Fatigue, lethargy or restlessness are also common. A maculopapular, blanching rash over the body occurs often on day 3-4 of fever and fades with time. DF is sometimes referred to as break-bone fever because of the intense fever.

Dengue hemorrhagic fever or Dengue shock syndrome (DHF/DSS) are different in that patients have the same symptoms but start to have signs of underlying serious infection particularly plasma leakage. Laboratory testing start to show leukopenia, shifting from neutrophils to lymphocytes, and thrombocytopenia which can be severe. Increased hematocrit, hypoalbuminemia and increased liver function tests occur which are part of the plasma leak. Patients will show increased abdominal tenderness, emesis, fluid accumulation including pleural effusions or ascites, mucosal bleeding, mental status changes including lethargy or restlessness, and hepatomegaly. Other signs of plasma leakage and hemorrhage occur with more severe disease including petechiae (e.g. positive tourniquet test), mucosal bleeding, and menorrhagia.

Viral antigen detection testing is available for diagnosis.

Tropical diseases associated with fever include:

  • Anthrax
  • Brucellosis
  • Carrion’s disease/Oroya fever
  • Chikungunya
  • Ebola
  • Human immunodeficiency virus
  • Japanese encephalitis
  • Lassa fever and other arenaviral infections
  • Leptospirosis
  • Lyme disease
  • Murray Valley encephalitis
  • Plague
  • Poliomyelitis
  • Q fever
  • Rabies
  • Rat lungworm
  • Relapsing fever/Borrelia
  • Rickettsioses
  • Riff Valley fever and other bunyaviral infections
  • Rubella
  • Scrub typhus
  • Typhus, endemic and epidemic
  • Sleeping sickness
  • Tetanus
  • Tick-born encephalitis
  • Toxoplasmosis
  • Yellow fever
  • Zika

A review of health affects of climate change can be found here.

Learning Point
There are 3 infection phases for Dengue:
1. Febrile
2. Critical – where patients will deteriorate and have symptoms of plasma leak and hemorrhage occurring for about 24-48 hours often (but not always) as the fever starts to subside (often day 3-7 but not always)
3. Convalescent – when patients improve with resolution of laboratory values and generally without health problems but they may have post-viral fatigue syndrome.


Most patients recover and mortality is 0.8-2.5% with children at increased risk especially those <5 years of age.

There is no specific treatment for Dengue. Treatment is only supportive. Patients who are overall well, able to maintain hydration and have no warning signs of impending hemorrhage are usually treated outpatient. Authors note that oral rehydration fluids work well but fluids that are red or brown in color should not be used as these could be mistaken for gastric hemorrhage. For patients with underlying health problems they are monitored in the hospital and treated accordingly. For patients with DHF/DSS they are treated aggressively for hemorrhage with fluid resuscitation and other measures meant to maintain organ function. Also non-steroid anti-inflammatory drugs should be avoided as they can increase the risk of bleeding.

Mosquito bite prevention is the primary prevention. Dengvaxia® vaccine was approved for use in the United States in May 2019 for persons living in endemic areas such as the US Territories of American Samoa, Puerto Rico and US Virgin Islands. Vaccines can be given to children 9-16 years. The dosing schedule is 3 doses each given 6 months apart. In other countries this vaccine can be given from ages 9-45 years.

Questions for Further Discussion
1. What are good travel health resources to find current information about specific destinations?
2. What are some health affects due to climate change? A review can be found here.
3. What patient education information do you provide to patients traveling internationally?

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 and the Cochrane Database of Systematic Reviews.

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

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.

Kularatne SA. Dengue fever. BMJ. 2015 Sep 15;351:h4661.

Khetarpal N, Khanna I. Dengue Fever: Causes, Complications, and Vaccine Strategies. J Immunol Res. 2016;2016:6803098.

Scaggs Huang FA, Schlaudecker E. Fever in the Returning Traveler. Infect Dis Clin North Am. 2018 Mar;32(1):163-188.

Centers for Disease Control. Dengue Fever. Available from the Internet at https://www.cdc.gov/dengue/ (rev. 5/3/19, cited 5/16/19).

Centers for Disease Control. Dengue Vaccine. Available from the Internet at https://www.cdc.gov/dengue/prevention/dengue-vaccine.html (rev. 5/3/19, cited 5/16/19).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Can You Do To Prevent Tinea Infections and Why?

Patient Presentation
A 16-year-old male came to clinic because of a groin rash that had been present for a week. It was only slightly bothersome because of the location and was slightly pruritic. He had tried some powder and also lotion but this did not help. The rash was now spreading circumferentially. He was a multi-sport athlete. The past medical history was positive for tinea pedis a few weeks previously that he had used anti-fungal cream for with resolution. He also had a history of tinea pedis more than 1 year ago. The family history was positive for a younger sister who was being treated for ringworm.
The review of systems was negative.

The pertinent physical exam showed a healthy appearing male with normal vital signs and growth parameters. His skin examination showed a 7 cm round-oval lesion in the left inguinal fold with lighter coloring in the center and a raised edge. It was difficult to tell if there was scale as he had just showered. There was a 3 cm lesion above the gluteal cleft that appeared similarly but had some scale present. All other areas of the skin appeared uninfected including his feet.

The diagnosis of tinea cruris was made. The pediatrician recommended over-the-counter antifungal cream to be used twice a day for at least 14 days. “Sounds like you are re-infecting yourself or you are getting infected from your sibling or all the sports you do.
I have some ideas about how you can prevent this from occurring again,” she said.

Discussion
Superficial fungal infections are very common. “Dermatophytes are molds that can invade the stratum corneum of the skin or other keratinized tissues derived from the epidermis, such as hair and nails. Organisms most commonly affect the scalp, feet, groin and nails.”

Dermatophytes can be anthropophilic (human to human transmission), zoophilic (animal to human transmission) or geophilic (fomite to human transmission). Zoophilic dermatophytes are usually uncommon sources of human infection. Microsporum canis is the most common zoophilic dermatophyte and it can infect humans with close contact but this is less common than anthropophilic organisms. A common example of a geophilic dermatophyte is Microsporum gypseum and again it is not very commonly spread. Human to human or self-inoculation is the most common way tinea infections are spread. Anthropophilic organisms commonly encountered include Trichophyton rubrum, Triphophyton mentagrophytes, Trichophyton tonsurans, and Epidermophyton floccosum.

A review of common tinea infections and presentations can be found here

Learning Point
Tinea tends to affect the glabrous skin or skin without prominent hair. The primary method of transmission between people is contact with infected desquamated skin scales and also infected hair. Molds tend to grow in warm humid environments, so it is not surprising that areas of the bodies with these characteristics are commonly affected. Similarly, environmental exposure such as public shower rooms where large numbers of people congregate may also increase the risk of acquiring or spreading some tinea infections especially tinea pedis. Other areas where infected scale or hair could be contacted would be shared combs, brushes, hats or other clothing.

Prevention of tinea includes not sharing personal items such as combs, brushes, worn and unwashed clothing, towels or bedding. Additionally, frequent clothes changes and washing of potentially infected clothing and towels/bedding should decrease the amount of potential infected material on the clothing, etc. thereby decreasing transmission. Affected body areas should be covered when around others or in venues where people could become infected (e.g. sports practices and competitions, etc.). However, increasing the airflow by wearing loose-fitting garments can decrease the humidity and temperature thereby potentially decreasing dermatophyte growth. Wearing shower shoes in communal bathing facilities is a good practice.

Some authors note that there is an increased risk of tinea cruris after an episodes of tinea pedis. They suspect that during clothing changes and/or grooming, the affected foot or feet is placed near the genital area in a semi-crossed legged position thereby increasing transmission risk. They recommend covering the feet with socks prior to dressing other areas of the body.
Treatment of tinea infections includes antifungal medication and mechanical debridement if appropriate such as nail hygiene.

Questions for Further Discussion
1. How do you treat fungal nail infections? A review can be found here
2. Why do you treat some fungal infections with topical medication and others with oral medication?

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 and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Tinea Infections and Fungal 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.

Gupta AK, Chaudhry M, Elewski B. Tinea corporis, tinea cruris, tinea nigra, and piedra. Dermatol Clin. 2003 Jul;21(3):395-400, v.

Panackal AA, Halpern EF, Watson AJ. Cutaneous fungal infections in the United States: Analysis of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1995-2004. Int J Dermatol. 2009 Jul;48(7):704-12.

Bhadauria S, Kumar P. Broad spectrum antidermatophytic drug for the control of tinea infection in human beings. Mycoses. 2012 Jul;55(4):339-43.

Alter SJ, McDonald MB, Schloemer J, Simon R, Trevino J. Common Child and Adolescent Cutaneous Infestations and Fungal Infections. Curr Probl Pediatr Adolesc Health Care. 2018 Jan;48(1):3-25.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common Are Cerebrospinal Fluid Leaks After Minor Head Trauma?

Patient Presentation
A 7-year-old male came to clinic for follow up after tripping and falling 6 days previously. He had hit his face on a table and then on the floor sustaining a contusion above his left eyebrow and having epistaxis. He denied any loss of consciousness or emesis. The epistaxis was controlled within 10 minutes and he was seen at a local emergency room, where he was found to have a small contusion, no nasal fracture or septal hematoma. He had a small blood clot on the lateral area of his nostril. Mental status, dental and neck examinations were reportedly normal. His mother said that in the evening he had a headache but had not had any others. She noted that he been doing his regular activities but was significantly more tired in the evenings and went to bed early. He reported no sleep disturbance or nausea, nor difficulties in speaking, talking or thinking. It was not taking him longer to do his work at school and he was able to play on the playground. His mother had kept him out of gym class. His mother noted that the contusion was improving and that he had expelled a small clot from his nose without additional bleeding, but had noted a small amount of rhinorrhea for a couple of days after the clot was expelled. She was concerned because she was a neurosurgical nurse and was worried about cerebrospinal fluid leaking. The rhinorrhea was not continuous and she had only noticed it a few times, with none in the past 1-2 days. The patient did not notice it. They denied any coughing or seasonal allergic rhinitis. The past medical history was notable for excessive cerumen that required intermittent debridement.

The pertinent physical exam showed a well-appearing male in no distress with normal vital signs. HEENT showed a tiny healing contusion above the left eyebrow. No other facial abnormalities were seen. His nasal examination showed no rhinorrhea, hematoma or bleeding. His pharynx was negative. His ears were blocked with cerumen. His neurological examination was negative.

The diagnosis of a healing facial contusion along with probably mild concussion was made. His mother was counseled that although the patient seemed to be doing well at school, that the excessive tiredness was probably due to mild concussion. The physician recommended additional brain rest for a couple of days over the weekend and then to monitor the patient once he resumed his normal activities. “I can understand why you would be concerned about the rhinorrhea but this is more likely due to his nose making some additional fluid to keep the area clean or that he could have had a cold. He didn’t have a nasal fracture, plus it was a low-velocity fall so it would be really unusual for this to be a facial or skull fracture causing a CSF leak,” the physician said. Two days later the boy was seen by otolaryngology for his regularly scheduled followup. They found normal nasal structures and no rhinorrhea.

Discussion
Basilar skulls fractures are relatively common occurring in 4-20% of all skull fractures. Motor vehicle accidents, significant falls from heights and blunt trauma are the most common causes of basilar skull fractures. Basilar skulls fractures are even less common in children than adults. Complications can include meningitis, cerebrospinal fluid (CSF) leaks, cranial nerve injuries or even potentially death. With more significant trauma to the head and body, it is not surprising that complications are more likely.

Nasoethmoid facial fractures have similar common mechanisms of injury including motor vehicle accident, falls, and pedestrian struck injuries.

A review of the timing for concussion symptom resolution can be found here.

Learning Point
CSF leaks can present as otorrhea or rhinorrhea with a basilar skull fracture. Most leaks occur within 48 hours of trauma and most stop without specific treatment usually within a couple of days. A study of hospitalized patients with isolated basilar skull fracture using hospital diagnosis data (N=3563 pediatric patients) found that rates were 2.3% for CSF leaks and 0.48% meningitis respectively.

In a long-term follow up study of post-traumatic basilar skull fractures in hospitalized children (N=196), 28% had CSF leak with 23% having rhinorrhea, and 89% of those stopped spontaneously. Those that didn’t had complicated presentations and courses. The authors state that for children with normal mentation, neurological examination and CT imaging findings in the emergency room after blunt head trauma, that basilar skull fractures have a low-risk of complications and patients can be discharged with outpatient followup.

For CSF leaks that do not spontaneously resolve, patients may be tried on medication that inhibits CSF production such as acetazolamide, and may have an external CSF drainage device placed. Surgical treatment is usually reserved for those with persistent leads more than 10-14 days or with complications.

In a study of 63 pediatric patients, the authors noted that nasoethmoid factures are uncommon fractures, that more simple fractures are often treated without surgical intervention and while complications can occur, they are usually in patients with more severe or multiple injuries. CSF leaking was not reported.

While it is true that any complication can occur in any patient, the patient above had a low-velocity injury, no nasal fracture or other known facial or skull fracture, or other major injury, and the rhinorrhea started several days after the event all of which are less common attributes for CSF leak. Additionally, most CSF leaks spontaneously resolve, therefore continued conservative management and observation was appropriate.

Questions for Further Discussion
1. After a concussion when can a child return to learning? A review can be found here.
2. What are indications for head computed tomography in head trauma?
3. How common are anatomical CSF leaks?

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 and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: https://medlineplus.gov/concussion.html and Head Injuries.

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.

Yilmazlar S, Arslan E, Kocaeli H, Dogan S, Aksoy K, Korfali E, Doygun M.
Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases.
Neurosurg Rev. 2006 Jan;29(1):64-71.

McCutcheon BA, Orosco RK, Chang DC, Salazar FR, Talamini MA, Maturo S, Magit A.
Outcomes of isolated basilar skull fracture: readmission, meningitis, and cerebrospinal fluid leak. Otolaryngol Head Neck Surg. 2013 Dec;149(6):931-9.

Leibu S, Rosenthal G, Shoshan Y, Benifla M.
Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.
World Neurosurg. 2017 Jul;103:315-321.

Lopez J, Luck JD, Faateh M, Macmillan A, Yang R, Siegel G, Susarla SM, Wang H, Nam AJ, Milton J, Grant MP, Redett R, Tufaro AP, Kumar AR, Manson PN, Dorafshar AH. Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.
Plast Reconstr Surg. 2019 Jan;143(1):211-222.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa