What is a Ganglion Cyst?

Patient Presentation
A 16-year-old male came to clinic with a 2 week history of a mass on the inside of his wrist. He had noticed it when he was keyboarding. He denied pain, irritation, redness, warmth or limitation of motion of the wrist. He also thought that it wasn’t getting larger but wasn’t going away. The past medical history and review of systems was non-contributory.

The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters. There was a ~10 mm round, mobile mass along the lateral, palmer aspect of the wrist. It was non-tender without changes in the overlying skin. He had complete range of motion that did not elicit tenderness. The mass transilluminated. The diagnosis of a ganglion cyst was made. The natural history of this potentially becoming larger or receding was discussed. Potential future options such as aspiration or surgery were also discussed but the family was told that they could often recur. The patient wanted to wait and watch.


Lumps and bumps in the pediatric age group are most often benign. They can be from unwitnessed/unrecognized trauma (e.g. leg bruise, Osgood-Schlater disease, insect bites), normal pubertal changes (e.g. gynecomastia, testicular enlargement, acne) or normal variants (e.g. prominence of mastoid or occipital process). Some are often uncomplicated but need appropriate treatment (e.g. early abscess formation, inguinal hernia, dermoid cyst). Prominent lymph nodes are a very common reason for parents to come to the physician. Patients and families are often distressed by these masses and seek help because “they weren’t there before” or “they’re not going away.” They are often surprised to find out that the mass is benign or normal but are happily reassured.

Learning Point
Ganglion cysts (GC) are cystic masses that can overlying a tendon, ligament, joint and occasionally a bone. They are benign but because of size or location may need treatment. GC are not considered true cysts as they do not have an epithelial cell lining. The etiology is unclear but the walls are made up of smooth muscle cell variants and there is mucinous fluid within. They can be solitary or multilobulated. Often they are not palpable and are found secondary to evaluation for other problems. GC can occur anywhere in the appendicular skeleton but wrists are a very common location and are the most common cause of wrist soft tissue masses in the general population. The incidence in the pediatric population is not known. Adults have more lesions on the dorsal surface and adolescents have more on the palmar surface. They can occur at any age in the pediatric age group and are more common in adolescents. In the pediatric age group, females have them more than males.

GC usually has low morbidity with potential spontaneous resolution and unfortunately a relatively high recurrence rate after various interventions. Evaluation may including imaging with ultrasound or magnetic resonance imaging (MRI) and both have equal effectiveness but ultrasound is significantly more cost effective. In a study of pediatric patients who had MRI imaging of their wrist, ~ 1/3 had a GC. Many had pain (82.9%), swelling (20%) or a palpable mass (11.4%). Most also had other significant wrist abnormalities and it was difficult to ascertain if these wrist symptoms were due to GC or GC was an incidental finding.

Interventions include aspiration, puncture rupture, steroid injection, open or arthroscopic excision. In a prospective study of adults with GC, 70 months after reassurance or treatment, the GC often did not resolve (58%) and 39% had recurrence after intervention. Patients who had intervention were more satisfied overall than patients who were reassured though. Surgical complications were 7.7%. Treatment costs obviously increased with intervention because of radiology, pathology and surgery costs.

GC are sometimes called “bible bumps” because laypeople would take the largest book they had in the house (i.e. a bible or similar book) and smash the lesion to treat it. This form of treatment is NOT recommended.

Questions for Further Discussion
1. What are common benign and malignant bone masses in adolescents?
2. What are indications for referral for a mass to a surgeon?

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: Wrist and Hand Disorders

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.

Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007 Oct;32(5):502-8.

Gant J, Ruff M, Janz BA. Wrist ganglions. J Hand Surg Am. 2011 Mar;36(3):510-2.

Bracken J, Bartlett M. Ganglion cysts in the paediatric wrist: magnetic resonance imaging findings. Pediatr Radiol. 2013 Dec;43(12):1622-8.

O’Valle F, Hernandez-Cortes P, Aneiros-Fernandez J, Caba-Molina M, Gomez-Morales M, Camara M, Paya JA, Aguilar D, del Moral RG, Aneiros J. Morphological and immunohistochemical evaluation of ganglion cysts. Cross-sectional study of 354 cases. Histol Histopathol. 2014 May;29(5):601-7.

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

What Causes Pelvic Pain?

Patient Presentation
A 15-year-old female came to the emergency room with abdominal pain for about 1 day. She describes the pain as at the lower right abdomen but said that it felt “even deeper” into her pelvis. The pain was constant and increasing in intensity without radiation. She had vomited twice after the pain began that was non-bilious and non-bloody. She was not eating but was trying to drink despite feeling quite nauseous. She denied any dysuria, but had a temperature of up to 102°F. She had had a normal bowel movement just before the pain began and had no history of constipation. During a private interview she confided that she had become sexually active with 1 male partner about 3 months ago and didn’t use condoms consistently or any other form of birth control. Her last intercourse was just before her normal period about 2 1/2 weeks previously and she had noticed increased vaginal discharge since around that time. She could not further describe the discharge. The past medical history was non-contributory. The family history was negative. The review of systems was negative for diarrhea and rashes, There were no previous surgeries.

The pertinent physical exam showed a cooperative adolescent in moderate pain. Her temperature was 101.7°F., pulse of 128, respiratory rate of 30 and had a normal blood pressure. HEENT, lungs and heart were non-contributory. Abdominal examination showed tenderness in the right lower quadrant especially near the pelvis with positive guarding and positive rebound tenderness. There was no abdominal rigidity. Her liver was non-tender and spleen was not palpable. She had no masses. There was no change with straight leg lifts or other skeletal maneuvers. Her external genital examination was negative. Her pelvic examination showed a yellow, slightly smelly vaginal discharge including some from the cervix. She had mild cervical motion tenderness without obvious masses or tenderness of the left ovaries or uterus. The right lower pelvic area was difficult to examine because of patient cooperation secondary to pain.

A working diagnosis of pelvic inflammatory disease versus appendicitis was considered. The laboratory evaluation showed a normal pregnancy test, liver function tests, amylase, lipase, electrolytes, BUN and creatinine. Her urinalysis had a specific gravity of 1.025, pH of 6 with negative nitrites and leukocyte esterase. Urine testing was positive for chlamydia, but negative for gonorrhea. An HIV performed later was negative. Her complete blood count had a normal hemoglobin, hematocrit and platelets. Her white blood cell count was 18.4 x 1000/mm2 with a 65% left shift. Her C-reactive protein was 2.5 mg/dl. The radiologic evaluation of an abdominal ultrasound was positive for an enlarged appendix. Over the next few hours the patient’s clinical course had her taken to the operating room where she had an uneventful appendectomy performed. The uterine structures appeared normal under direct visualization and palpation. She was discharged 48 hours after surgery because of post-op emesis. She was also treated for chlamydia, started on Depo-Provera® for contraception and was counseled about consistent use of condoms to prevent sexually transmitted infections. Treatment was arranged for her partner. Followup with adolescent medicine and surgery was arranged before discharge.

Appendicitis results from a closed loop obstruction of a blind-ending tubular structure arising from the cecum. It is a common cause of abdominal pain. It is the most frequent condition leading to emergent abdominal surgery in pediatrics. The combination of obstruction, edema, bacterial overgrowth, increased inflammatory process and increased intraluminal pressure leads to abdominal pain and possibly perforation. Appendicitis occurs in all age groups but is rare in neonates. The peak age is 6-10 years old.

Pelvic inflammatory disease (PID) is an inflammatory disease of the uterus, fallopian tubes and adjacent pelvic structures caused by ascending microorganisms from the vagina and cervix particularly Neisseria gonorrhea and Chlamydia trachomatis. Increased risks for PID includes early age at first intercourse, multiple sexual partners, intrauterine device insertion and tobacco smoking. The Centers for Disease Control’s Sexually Transmitted Disease Treatment Guidelines can be found here.

The causes of pelvic pain and abdominal pain necessarily overlap a great deal due to the proximity of anatomic structures as this case illustrates.

Acute pelvic pain is defined as 6 months of noncyclic pain that is at the umbilicus or lower.

Complete histories and good general physical examinations are important to guide the differential diagnosis. Pelvic examination may or may not be indicated. Laboratory testing especially to determine pregnancy status also helps guide diagnosis. General testing such as complete blood counts, C-reactive protein and Erythrocyte sedimentation rates can be helpful in addition to urine testing for sexually transmitted diseases. Imaging particularly by ultrasound is also important to narrow the diagnosis and determine treatment plans.

Learning Point
The differential diagnosis of pelvic pain includes:

  • Acute pelvic pain
    • Non-pregnant
      • Simple ovarian cysts
      • Ruptured or hemorrhagic ovarian cysts
      • Pelvic inflammatory disease
      • Endometritis
      • Pelvic abscesses – tubo-ovarian abscesses
      • Ovarian torsion
      • Intrauterine device malpositioned
    • Pregnant
      • Pregnancy
      • Corpus luteum cyst
      • Subchorionic hemorrhage
      • Spontaneous abortion
      • Ectopic pregnancy
    • Post partum
      • Retained products of conception
      • Endometritis
      • Ovarian vein thromphlebitis
      • Cesarian section
    • Other
      • Appendicitis
      • Adhesions
      • Malrotation
      • Musculoskeletal pain
      • Sickle cell anemia
      • Tumor
      • Renal stones
      • Urinary tract infection
  • Chronic pelvic pain
    • Genitourinary
      • Ovarian cysts
      • Endometriosis
      • Uterine outflow tract obstruction and congenital abnormalities – imperforate hymen
      • Pelvic inflammatory disease
    • Gastrointestinal
      • Constipation
      • Food sensitivity or intolerance – lactose intolerance
      • Gastroesophageal reflux
      • Inflammatory bowel disease
      • Irritable bowel syndrome
      • Meckel’s diverticulum
      • Pancreatitis – chronic, relapsing
      • Peptic ulcer disease
    • Neurologic / Psychologic
      • Abdominal epilepsy
      • Abdominal migraine
      • Abuse – physical and sexual
      • Factitious
      • Fibromyalgia
      • Nerve entrapment
      • Munchausen by proxy
      • Psychological stress, anxiety, depression
    • Musculoskeletal
      • Abdominal wall strain
      • Pelvic musculature strain
    • Renal
      • Cystitis
      • Hydronephrosis
      • Renal stones
    • Miscellaneous
      • Adhesions
      • Autoimmune diseases that may have dermatologic or mucous membrane symptoms
    • Inguinal hernia

Questions for Further Discussion
1. What are indications for referral to gynecology or surgery?
2. What are indications for a pelvic examination?

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: Topic

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.

Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet Gynecol Clin North Am. 2011 Mar;38(1):85-114, viii.

Youngster M, Laufer MR, Divasta AD. Endometriosis for the primary care physician. Curr Opin Pediatr. 2013 Aug;25(4):454-62.

Powell J. The approach to chronic pelvic pain in the adolescent. Obstet Gynecol Clin North Am. 2014 Sep;41(3):343-55.

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

What Causes Vomiting?

Patient Presentation
A 4-year-old female came to clinic with a history of increasing rhinorrhea, coughing for 10 days, emesis and poor sleep. Her mother said that the rhinorrhea was clear but was in copious amounts and the cough was described as “phlegmy.” The patient had used her albuterol inhaler without much relief. The emesis was non-bilous, non-bloody and “looked like the cold coming out her nose.” Her mother noted that she frequently would gag. The mother stated that she would lie down, then after a while would start coughing forcefully and then she would have emesis. This was occurring at night and was bothering both the child’s and mother’s sleep. She did not have emesis at other times. The mother thought that the rhinorrhea and cough had started after exposure to other ill children at daycare. The family had pet fishes but no other animals in the home. The past medical history revealed a child with mild intermittent asthma and atopic dermatitis that was well-controlled with intermittent albuterol and lubricants. The family history was positive for asthma, seasonal allergic rhinitis and atopic dermatitis. There was no history of gastrointestinal diseases. The review of systems was negative for fever, chills, constipation, and nausea, but was positive for dry skin.

The pertinent physical exam showed a tired appearing female who was appropriately responsive. Vital signs were normal with growth parameters in the 10-25% for age. HEENT showed dark circles under her eyes with atopic pleats. Her conjunctiva showed mild erythema with some cobblestoning. Her nose was boggy with copious clear rhinorrhea. Pharynx and ears were normal. Her lungs had no wheezing and her skin examination showed general xerosis without acute inflammation. The diagnosis of a probable upper respiratory infection starting the rhinorrhea and cough, but with components of allergic rhinitis was made.. The mother was counseled that the emesis was because of an appropriate gag reflex because of the post-nasal drip. The patient was started on cetirizine to help with the allergic rhinitis, and counseled. The physician also counseled about decreasing exposure to environmental allergens particularly as it appeared that the child and family all had environmental allergies.

Regurgitation is a passive expulsion of ingested material out of the mouth. It is a normal part of digestion for ruminants such as cows and camels. Nausea is an unpleasant abdominal perception that the person may describe as feeling ill to the stomach, or feeling like he/she is going to vomit. Anorexia is frequently observed. Nausea is usually associated with decreased stomach activity and motility in the small intestine. Parasympathetic activity may be increased causing pale skin, sweating, hypersalivation and possible vasovagal syndrome (hypotension and bradycardia). Retching or dry heaves is when there are spasmodic respiratory movements against a closed glottis. This often occurs just before emesis.

Emesis, vomiting or vomition is when stomach (sometimes small intestine also) contents are propelled up the esophagus and out the mouth.
It is composed of three basic parts:

  • A deep breath is taken, the glottis closed to prevent aspiration into the lungs, while the larynx is raised which helps to open the upper esophageal sphincter. There is a decrease in respiration.
    The soft palate also closes to try to protect the posterior nares. The pylorus also contracts.

  • The diaphragm contracts downward sharply which creates negative thoracic pressures. This also assists the opening of the lower esophageal sphincter and the esophagus itself.
  • As the diaphragm contracts, the abdominal wall muscles vigorously contract which increases the intragastric pressure. As the pylorus is closed, the path of least resistance is through the relatively open esophagus.

A differential diagnosis of bilious emesis in a neonate can be found here.
A differential diagnosis emesis in a neonate can be found here.
A differential diagnosis of hematemesis can be found here.

Learning Point
The differential diagnosis of emesis include:

  • Normal variation, i.e. “spitting up”
  • Feeding problems
    • Overfeeding or force feeding
    • Incorrect feeding – delay in giving solid foods and food aversion
    • Refeeding syndrome
  • Excessive crying
  • Gastroesophageal reflux, severe
  • Gastrointestinal obstruction
    • Achalasia
    • Annular pancreas
    • Diaphragmatic hernia
    • Gastric/intestinal atresia/stenosis/duplications
    • Incarcerated hernia
    • Intestinal or viscous organ perforation with peritonitis
    • Intussception
    • Imperforate anus
    • Hirschsprung disease
    • Malrotation/volvulus
    • Meconium plug and ileus
    • Organomegaly
    • Pseudoobstruction syndrome
    • Pyloric stenosis
    • Superior mesenteric artery syndrome
    • Tumor
    • Tracheoesophageal fistula
    • Vascular rings
  • Gastroenterology, other
    • Constipation/encopresis
    • Celiac disease
    • Foreign body – esophageal, lactobezoar
    • Nutrient intolerance – lactose intolerance
    • Sensitive gag reflex
    • Swallowed blood – epistaxis and maternal
  • Allergy/Respiratory
    • Allergies
    • Cystic fibrosis
    • Asthma
  • Drug overdose
    • Aspirin
    • Iron
    • Lead
    • Theophylline
    • Digoxin
  • Genitourinary
    • Inguinal hernia
    • Testicular or ovarian torsion
    • Pelvic inflammatory disease
    • Pregnancy
  • Infections
    • Appendicitis
    • Cholecystitis
    • Encephalitis, meningitis, brain abscess
    • Gastroenteritis
    • Hepatitis
    • Necrotizing enterocolitis
    • Otitis media
    • Pancreatitis
    • Peptic ulcer disease
    • Pertussis
    • Perihepatitis
    • Peritonitis
    • Sepsis
    • Urinary tract infection
  • Metabolic
    • Diabetic ketoacidosis
    • Hyperammoninemia
    • Inborn errors of metabolism
      • Aminoacidemia
      • Congenital adrenal hyperplasia
      • Galactosemia
      • Hypercalcemia
      • Organic acidemia
      • Urea cycle defects
    • Reye’s syndrome
  • Neurologic
    • Cerebral edema
    • Cyclic vomiting
    • Familial dysautonomia
    • Head trauma
    • Hydrocephalus
    • Intracranial bleeding
    • Kernicterus
    • Mass lesion
    • Migraine
    • Seizures
    • Vestibular disorders – motion sickness
  • Psychological/Psychiatric
    • Attention seeking
    • Strong emotions – anxiety, fear
    • Intentional – bulimia
    • Munchausen by proxy
    • Neglect – rumination
    • Psychogenic
  • Renal
    • Obstruction
    • Uremia
  • Surgery and Trauma
    • Post-anesthesia
    • Non-accidental trauma

Questions for Further Discussion
1. How is bilious emesis defined?
2. What are “red flags” for potential serious causes of emesis?
3. What are the most common causes of emesis at different ages?

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: Nausea and Vomiting.

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.

Sheldon SH, Levy HB. Pediatric Differential Diagnosis. Second Edition. Raven Press: New York. 1985:167-174.

R. Bowen. Physiology of Vomiting. Available from the Internet at http://www.vivo.colostate.edu/hbooks/pathphys/digestion/stomach/vomiting.html (rev. 4/10/96, cited 3/1/16).

Di Lorenzo C, Gastroesophageal Reflux in Pediatrics a Primary Care Approach. Berkowitz C. edit. W.B. Saunders Company, Philadelphia PA. 1996:334-339.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1351-1354.

Colosini DM. Nausea and Vomiting in Infants and Children. Merck Manual. Available from the Internet at http://www.merckmanuals.com/professional/pediatrics/symptoms-in-infants-and-children/nausea-and-vomiting-in-infants-and-children (rev. 8/2013, cited 3/1/16).

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

What Do You Do When the Rabies Vaccination Schedule is Off Schedule?

Patient Presentation
A 3-year-old male with his mother walked into clinic requesting rabies vaccination. Five days previously, the child had been playing in his bedroom alone and had a bat fly directly at him from a closet. He said the bat had hit or bit him on the arm. He cried. His father came, caught the bat and released the bat. The boy was evaluated at a local emergency room later that day and was given rabies vaccine but no rabies immunoglobulin because it was not available. The boy was supposed to followup at his local doctors on day 3 after the incident but the mother said that she had transportation issues and couldn’t go. She was now visiting relatives and they helped bring the child to general pediatric clinic. The past medical history revealed a healthy male with intermittent medical care but who was fully vaccinated. He had been seen in this clinic 2 years previously for his 9 and 12 month health supervision visits. The social history showed a family who was working but having financial struggles. There had been other bats seen in the home before.

The pertinent physical exam showed a healthy male with normal vital signs. His weight and height were at the 75-90% for age. He had a 10-15 mm red spot on his right dorsal forearm that he said was where the bat hit/bit him. There were no obvious bite marks and the area did not look infected. The rest of his examination was normal.

The diagnosis of a probable rabies exposure through a bat bite was made. The resident and attending physician had many questions about how best to treat the patient and consulted online resources as well as contacting the Centers for Disease Control and the state Department of Public Health to come up with a plan. The questions were how to appropriate schedule the rest of the rabies vaccines for the patient who was now off schedule, can rabies immune globulin still be given at day 5, what should be done for bat control in the house, and how can they help the family come back for the additional vaccines on schedule? The patient was given rabies vaccine (second dose, “Day 3 vaccine”) while in clinic, along with rabies immunoglobulin. The 3rd dose of rabies vaccine was scheduled in 4 days time. The clinic social worker worked with the health care providers and family to identify potential resources for transportation back to the clinic, bat-proofing the house and also resources to have the father treated for potential rabies as it was later determined that he had not been treated yet and had captured the bat with his hands and wasn’t sure if he had been bitten also.

At followup 4 days later the child received his 3rd rabies vaccine, the family was working on batproofing the house, but the father had not been treated because of lack of medical insurance. He was scheduled to receive his 4th vaccine in another 7 days (“Day 14 dose”) and then was to followup again to have rabies serology testing 7-14 days after the last vaccine dose. The CDC and health department both indicated this should be done because the schedule had to be modified.

Rabies virus causes progressive encephalopathy and has a high fatality rate if not treated. Fortunately, post-exposure prophylaxis (PEP) regimens are highly effective. Any mammal is susceptible to rabies vaccine with domesticated dogs being important sources in some international locations and in the U.S. coyotes, fox, raccoon, and skunk and bats are important reservoirs.

Rabies transmission from bats “…can occur from minor, seemingly unimportant, or unrecognized bites from bats.” Therefore contact should be minimized. PEP is considered for people who had significant contact, were known to be bitten or were in a room and might be unaware that the bat touched them or bit them. Examples would be a sleeping person or a child who was unattended and is now found to have a bat in the room.

Current rabies vaccine schedule is a 4 dose series – Day 0, 3, 7 and 14. A fifth dose is given on day 28 for immunocompromised individuals. Vaccination is considered safe for pregnant women and should be given if PEP is indicated. Rabies immunoglobulin is also recommended to be given on Day 0. Once the PEP series is started it generally is continued. One reason to stop is if the bat tests negative for rabies, then the PEP can be stopped. It is recommended to consult current resources such as the Centers for Disease Control or local health department regarding current PEP treatment and individual circumstances.

Learning Point
It is important for the PEP to be given on the appropriate schedule. However, if a patient becomes off schedule for the PEP, the series is not restarted. “Every effort should be made to adhere to the recommended PEP regimen schedule, especially the first two days of treatment, days 0 and 3. After day 3 of the regimen, deviations of a few days are acceptable. For most minor delays or interruptions, the vaccination schedule can be shifted and resumed as though the patient were on schedule. For example, if a patient misses the dose scheduled for day 7 and presents for vaccination on day 10, the day 7 dose should be administered that day, and the final dose given one week later on day 17.”

Rabies virus can persist in tissue for a long time before moving into a peripheral nerve. Rabies immunoglobulin can be used up to and including 7 days after the exposure.

Identification of where the bats are living in the house is sometimes easy but often can be difficult or impossible. At dusk the bats can sometimes be seen moving in and out of the house and then steps to close up the openings can be made. If control measures cannot be successfully implemented then pre-exposure vaccination can be considered.

Questions for Further Discussion
1. How do PEP regimens change if a person has been previously vaccinated?
2. What are indications for pre-exposure rabies vaccination?

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: Rabies and Animal Bites.

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.

Iowa Department of Public Health. Available from the Internet at http://www.idph.state.ia.us/IDPHChannelsService/file.ashx?file=7D53ED18-4B3C-4087-AA8C-735B90EC8C25 (rev. 5/21/2010, cited 2/9/16).

New York State Department of Public Health. Guidance Regarding Human Exposure to Rabies and Postexposure Prophylaxis Decisions. Available from the Internet at https://www.health.ny.gov/diseases/communicable/zoonoses/rabies/docs/genguide.pdf (rev. 9/21/10, cited 2/9/15).

Centers for Disease Control. Precautions or Contraindications for Rabies Vaccination. Available from the Internet at http://www.cdc.gov/rabies/specific_groups/doctors/vaccination_precautions.html (rev. 6/30/11, cited 2/9/16).

Centers for Disease Control. Rabies Vaccine. Available from the Internet at http://www.cdc.gov/rabies/medical_care/vaccine.html (rev. 9/24/14, cited 2/9/15).

Hanlon CA, Schlim DR. Infectious Disease Related to Travel – Rabies. Centers for Disease Control. Available from the Internet at http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/rabies (rev. 6/30/15, cited 2/9/15).

Minnesota Department of Health. Rabies Post-Exposure Prophylaxis Regimen Animal Bites and Rabies Risk: A Guide for Health Professionals. Available from the Internet at http://www.health.state.mn.us/divs/idepc/diseases/rabies/risk/postexposure.htm (cited 2/9/16).

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