Patient Presentation
A 15-month-old male came to the emergency room because of diarrhea for < 24 hours that was not improving, fever to 100.8°F and fatigue. He had loose, watery non-bilious, non-mucous stools that would come out of his diapers. He had been trying to drink and had not vomited but was taking less and less orally over the day. His father was not able to tell when his last urine was because of the diarrhea. "There was an email yesterday that the daycare had another child with rotavirus," he offered.
The past medical history showed he had two ear infections and several viral infections including a documented influenza infection. Record review noted he was vaccinated for some diseases but not rotavirus.
The pertinent physical exam showed a very tired appearing male who was curled up in his father’s lap. He was alert and could cry appropriately but without tears. His vital signs showed heart rate of 106 beats/minute, blood pressure of 86/52, temperature of 100.5°F, and weight of 11.25 kg which was down from 12.36 kg in a visit the week before in his physician’s office. His mucous membranes were tacky and his capillary refill was > 3 seconds. His abdomen seemed overall slightly diffusely tender but without guarding, masses or organomegaly.
The diagnosis of acute gastroenteritis with dehydration was made. Two emergency room professionals felt that the smell of the diarrhea was consistent with rotavirus based on their past clinical experience. The work-up included starting an IV and drawing blood that was consistent with pre-renal dehydration. He started to appear somewhat better after his second IV fluid bolus, and after the third one, he started to drink some. His abdominal pain also seemed to improve. He was monitored in the emergency room overnight, and while he had more diarrhea, he started to have more free urine output and was drinking well before discharge.
Discussion
Rotaviruses (RV) are a leading cause of severe, acute, dehydrating diarrhea for children particularly those under age 5 years globally. As RVs are highly contagious and in the pre-RV era they caused an estimated 30-50% of hospitalizations for gastroenteritis yearly or about 111 million cases yearly. They also caused an estimated 500,000/year pediatric deaths.
RV are double-stranded RNA viruses of the genus
Clinical symptoms include non-bloody (usually) diarrhea, and can also include nausea, emesis, and abdominal pain. Electrolyte imbalance and dehydration can easily occur because of multiple loose or liquid stools that can be smaller or voluminous. Dehydration itself obviously can have its own severe consequences which as noted above can cause significant morbidity and mortality. Systemic symptoms such as fever, and fatigue are common. The diarrhea occurs through osmotic, secretory and neurogenic pathways. Laboratory testing is consistent with a limited inflammatory response. Other systemic problems can occur through viremia and antigenemia including seizures and other central nervous system disease, biliary atresia, lower respiratory tract infections, and there appears to be a role in autoimmunity including Celiac disease, and Diabetes mellitus type 1. Disease does protect against subsequent infections, but remember there are more than 1 species. While the majority of infections occur in those under age 5, it can still occur in older ages.
Learning Point
RV vaccine introduction has been an extraordinary global public health achievement. RV vaccination is recommended for young children globally since 2006. The timing and number of doses depends on the particular vaccine, with most starting after 6 weeks of age. These are live-attenuated vaccines which are highly effective in reducing the proportion of RV associated acute gastroenteritis by 50% overall globally, with also a concurrent significant reduction in mortality. Estimates of effectiveness are around 90%, 80% and 40-50% for high, middle and low-mortality countries depending on the specific vaccine. This heterogeneity of effectiveness is based on country with more occurring in lower to mid- mortality countries and is likely multifactorial including nutritional status, co-infections, microbiome, maternal antibiotics and co-administration of polio vaccine.
Potential common vaccine adverse effects include appetite loss, fussiness, diarrhea, abdominal pain, emesis, fever and weakness. Overall safety is excellent with current vaccines. In 1999, the first RV vaccine RotaShield was withdrawn because of increased risk of intussception which has not been seen with subsequent RV vaccines.
Questions for Further Discussion
1. How is Norovirus similar to Rotavirus? A review can be found here
2. What is the physiology of vomiting? A review can be found here
3. What causes abdominal pain? A review can be found here
Related Cases
- Disease: Rotavirus Infections | Childhood Immunization
- Symptom/Presentation: Diarrhea | Dehydration |
Fever and Fever of Unknown Origin
- Specialty: Emergency Medicine | Gastroenterology | Infectious Diseases
- Age: Toddler
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: Rotavirus Infections and Diarrhea.
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.
Caddy S, Papa G, Borodavka A, Desselberger U. Rotavirus research: 2014-2020. Virus Res. 2021;304:198499. doi:10.1016/j.virusres.2021.198499
Cates JE, Tate JE, Parashar U. Rotavirus vaccines: progress and new developments. Expert Opin Biol Ther. 2022;22(3):423-432. doi:10.1080/14712598.2021.1977279
Karolina Pawluszkiewicz, Ryglowski PJ, Idzik N, et al. Rotavirus Infections: Pathophysiology, Symptoms, and Vaccination. Pathogens. 2025;14(5):480. doi:10.3390/pathogens14050480
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa