Rotavirus presentation

This weekend I had a interesting presentation on Rotavirus presentation in our local IAP (Indian Academy of Pediatrics) meet of Pediatricians of Chandigarh, Panchkula & Mohali tri-city.


What is the rotavirus? Just the commonest cause of diarrhea in children, killing more than 1 lakh children in India alone!


You can get the entire presentation here. It was fun to read up this disease, since in office practice I tend to not get in a lot of academic reading about specific illnesses. While I am using the presently only available Rotavirus vaccine (Rotarix by GSK), there were still a few surprises for me. The large number of deaths worldwide caused by this virus were astounding, more so the fact (as you can read in the presentation ) that India has the largest number of deaths by far.


Since the presentation, I would probably be a bit more aggressive in suggesting this vaccine to affording parents with children under the age of 6 months. While the vaccination is at present slightly expensive (around INR 1,000 - 1,500 per dose), since it is imported and being marketed by a multinational, an Indian Rotavirus Vaccine is likely in the next few years, making a serious dent to the large number of preventable deaths due to rotavirus.

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A simple case of misdiagnosis .....

Being a doctor I always feel that there would be less chances of misdiagnosis in my case. I know the doctors, their reputation, and many are friends too. So this weekend when I developed pus in my tonsils, I first took a course of "mild" antibiotic Azithromycin. Since that did not work, I talked to an ENT specialist friend, and he recommended a course of Clindamycin, after having a look and saying that I had a lot of pus in both the tonsils. For those of you who have taken this medicine, you know the gastritis, loose motions etc. that are a part and parcel of taking it. However, I did take this as directed. However after 3 days of continuously missing my clinic practice due to fever, body aches and general malaise, I got a second opinion from another ENT specialist today. He had a look, and immediately exclaimed that this is a VIRAL tonsillopharyngitis, and it would recover faster with just a short course of oral steroids. No need for any antibiotics! This was amazing, and I am starting to feel better already :-)


I asked him and searched online for tips regarding how to differentiate the two conditions, since we do get a lot of purulent tonsillitis in my pediatric practice too.


While of course there are no hard and fast rules, generally viral tonsillitis would have small ulcers else where too, other than the tonsils, and the tonsils would not be angry red or enlarged. There would be more pain during speaking, and lots of malaise, but not very high fever nor toxic look in cases of children with viral tonsillitis. Small ulcerations on the other areas of the throat would be pathognomonic for viral tonsillitis, though in cases of doubt, a simple blood count would help differentiate the two conditions. Scratchy feeling in the throat, and other symptoms like cold, cough etc. are likely to occur. Generally the neck lymphnodes are not significantly enlarged nor painful in viral pharyngitis. Viral purulent tonsillitis is less common in children, and starts appearing in teenagers and older adults.


Strep tonsillitis is the most important differential between commonly occurring between 3-15 years age. Bacterial pharyngitis generally has higher fever, no flu like symptoms, and painful enlarged lymphnodes. There may be a petechial rash over the palate / uvula. Strep throat swabs are not easily available / routinely used in India at present, though this is likely to change, so immediate diagnosis is not possible, and antibiotics are generally given to everyone with purulent tonsillitis.


Well a lesson learnt about viral / bacterial tonsillopharyngitis, and that even simple conditions can be misdiagnosed leading to unnecessary suffering and missed work. While we do read about this, it really hits home when it happens to you I guess!


The other thing that I realized was that even for a "trivial" illness like tonsillitis, finding a better doctor can make such a difference, imagine how much difference it would make for serious and life threatening diseases?!

Leg Cramps- Nocturnal

Leg cramps- Nocturnal

This is strictly not a pediatric topic. I will be discussing pediatric leg cramps in a different post. A close relative suddenly started waking up with calf pain and tightness that soon became disabling. She had ‘taut’ calf muscles that used to cause an inability to walk in the morning/ walk with great difficulty, over the day this gradually reduced and she was almost well by the evening. This would return the next morning with a vengeance. There was no set pattern and she had good days and bad. None of the usual stuff like massage, oral pain-killers and hot fomentation were very effective. Consulting a physician lead to a possibility of hypocalcemia, thyroid abnormalities etc. the calcium reprts were borderline whle the thyroid reports were fine. A reputed endocrinologist suggested the possibility of Nocturnal leg cramps.

However on reading a lot of information (& I will provide the links below) on the net, I could not find any specific reference to what she was having. Nocturnal leg cramps are supposed to affect people in the sleep, they are supposed to wake up in the night with severe cramping pains, she had none of these symptoms.

Starting her on calcium, Vit D and vitamin E was suggested. Initially there was little improvement. On further online research we found that it was recommended that the supplements (calcium, magnesium, Vit E, Vitamin C etc.) should be taken in the night, and that a higher dose (1200 mg of calcium) should be consumed. On starting this she had a very rapid recovery and is now feeling much better! Of course she is also doing a few calf stretching exercises that are prescribed along with supplements for this condition.

A couple of interesting things, the patient is a young lady of around 30 years, and she consumes a lot of dairy products, both of these should not predispose her to nocturnal cramps and hypocalcemia.

More tips

• Eliminate as much sugar and caffeine as possible from the diet.

Supplement doses

• Calcium: 1,200 mg. at bedtime,
• Vitamin E: 400 I.U. twice a day after meals for two weeks. If symptoms are relieved, cut down to 400 I.U. once a day, If symptoms recur, up the dosage until symptoms are relieved but never take more than 1,200 I.U. daily,

If neither calcium nor vitamin E gives you relief, you may benefit from magnesium, potassium, or vitamin A.

• Magnesium: 400 mg. daily. (many a times found with calcium)
• Vitamin A: 10,000 I.U. daily.
• Potassium: 100 mg./daily, Make sure you eat plenty of potassium rich foods - (bananas, tomatoes, potatoes, broccoli, cantaloupe, oranges, grapefruit)

Source- http://alternative-medicine-and-health.com/conditions/legcramp.htm

Prevention

To stave off future episodes of nocturnal leg cramps, consider the following tips:

• Drink six to eight glasses of water daily. Doing so will help prevent dehydration, which may play a role in the cramping.
• Stretch calves regularly throughout the day and at night. (See box below for more information.)
• Ride a stationary bicycle for a few minutes before bedtime. This activity can help prevent cramps from developing during the night, especially if you do not get a lot of exercise during the day.
• Keep blankets loose at the foot of the bed to prevent your toes and feet from pointing downward while you sleep.
• Do aquatic exercises regularly during the week to help stretch and condition your muscles.
• Wear proper foot gear.

Source- http://www.postgradmed.com/issues/2002/02_02/pn_legcramps.htm

Leg Exercise tips:

Nocturnal muscle cramps can often be prevented by doing leg-stretching exercises, such as the one outlined below.

1. Stand 30 inches from the wall.

2. While keeping your heels on the floor, lean forward, put your hands on the wall, and slowly move your hands up the wall as far as you can reach comfortably.

3. Hold the stretched position for 30 seconds. Release.

4. Repeat steps 1 through 3 two more times.

5. For best results, practice this exercise in the morning, before your evening meal, and before going to bed each night.

Source- http://www.postgradmed.com/issues/2002/02_02/pn_legcramps.htm

It is important to differentiate leg pain from cramps. Neuropathy (nerve damage), sciatica, as well as clogged arteries in the leg (vascular disease) can cause leg pain. These types of pain, tend to occur throughout the day and not just at night. Vascular disease also causes cramping with walking.

Source- http://www.healthcaresouth.com/pages/askthedoctor/Nocturnallegcramps.htm

This information is not a substitute for medical diagnosis and treatment and is meant for patient education only.