Chickenpox

Chickenpox and shingles are two diseases caused by the same virus, varicella. The virus is similar to the herpes virus, the roseola virus, and to the Epstein-Barr virus (which causes mononucleosis).

It used to be that most children caught chickenpox as children. The virus is spread by droplets coughed or sneezed out by someone who is already infected. The signs of a chickenpox infection are fever and malaise, followed by the typical rash. The "poxes" start as small red spots, which become red bumps and then develop a small "vesicle", or bubble of clear fluid in the middle. Eventually the vesicle breaks, the "pox" crusts over, dries, and then falls off. The rash usually appears first on the head (often along the hairline), then spreads over the entire body in successive "crops" of new "poxes". An infected child is thought to be contagious from 1-4 days before the rash appears until all of the "poxes" have crusted over. (There is some evidence that a child is no longer contagious 6 days after the rash starts, but most people will wait until all of the "poxes" are crusted just to be safe.)

In toddlers and school-age kids, the fever, malaise, and rash are usually all there is to chickenpox. One exception to this is bacterial "superinfection" of a "pox", which can be treated with antibiotic ointment or oral antibiotics. In infants and older people (late teens and up), and in people with immune-system problems (such as cancer patients, but also including people taking lots of steroids for asthma, eczema, or other diseases) chickenpox can be much more serious, and sometimes fatal. The complications can include chickenpox-viral pneumonia, as well as damage to other organs. However, these complications are extremely rare in preteen and early-teen children.

Shingles is caused when the chickenpox virus (which the body never really gets rid of completely) is reactivated after many years. The rash of shingles is usually limited to a strip of skin somewhere on the body (the strip is the area of skin covered by a single nerve, and the virus usually lies dormant in the nerve root after the initial chickenpox infection). People who have shingles are contagious (someone who has not had chickenpox can get chickenpox after exposure to a person with shingles), but they are less contagious than patients with full-blown chickenpox.

Chickenpox can be treated with immune globulin, which provides passive immunity, and with acyclovir, which slows down or stops reproduction of the virus. These treatments are generally given only to people for whom chickenpox is dangerous (cancer patients, immune-compromised people, and adults); in preschool and school-age kids chickenpox is fairly benign and treatment is often not warranted -- and may prevent development of full immunity, leaving the child vulnerable to a more serious infection as an adult.
There is a vaccine available for chickenpox. The data we have so far indicates that one dose provides lifelong immunity in about 80-85% of children who receive the vaccine. New evidence (published in the New England Journal of Medicine in March, 2007) indicates that the immunity from a single dose of vaccine may wear off with time. We now recommend that children age 1-12 years receive two doses -- one at age 1 year, and one 3 months after the first dose -- to be sure of developing full immunity. Children who are 13 years old or older, and adults, who have not had chickenpox should receive two doses of vaccine at least 4 weeks apart. The vaccine is required by most American states for school entry. A combination vaccine, called "MMRV", contains both the chickenpox vaccine and the vaccines against measles, mumps, and rubella (German measles), and protects against all four diseases with fewer needle pokes. Although having natural chickenpox definitely confers lifetime immunity, as more and more children are vaccinated against chickenpox it is becoming more and more difficult to contract the natural disease. Therefore, I encourage parents of younger children to receive the vaccine. As chickenpox vaccination becomes more commonplace, it may be possible to eliminate chickenpox as we have eliminated smallpox and may soon eliminate polio -- but eliminating chickenpox won't happen without universal vaccination.

Diphtheria

Diphtheria is a bacterial infection that spreads easily and occurs quickly. It mainly affects the nose and throat. Children under 5 and adults over 60 years old are particularly at risk for contracting the infection. People living in crowded or unclean conditions, those who aren't well nourished, and children and adults who don't have up-to-date immunizations are also at risk.

Diphtheria is rare in the United States and Europe, where health officials have been immunizing children against it for decades. However, it's still common in developing countries where immunizations aren't given routinely. In 1993 and 1994, more than 50,000 cases were reported during a serious outbreak of diphtheria in countries of the former Soviet Union.
Signs and Symptoms

In its early stages, diphtheria can be mistaken for a bad sore throat. A low-grade fever and swollen neck glands are the other early symptoms.

The toxin, or poison, caused by the bacteria can lead to a thick coating in the nose, throat, or airway. This coating is usually fuzzy gray or black and can cause breathing problems and difficulty in swallowing. The formation of this coating (or membrane) in the nose, throat, or airway makes a diphtheria infection different from other more common infections (such as strep throat) that cause sore throat.

As the infection progresses, the person may:

* have difficulty breathing or swallowing
* complain of double vision
* have slurred speech
* even show signs of going into shock (skin that's pale and cold, rapid heartbeat, sweating, and an anxious appearance)

In cases that progress beyond a throat infection, diphtheria toxin spreads through the bloodstream and can lead to potentially life-threatening complications that affect other organs of the body, such as the heart and kidneys. The toxin can cause damage to the heart that affects its ability to pump blood or the kidneys' ability to clear wastes. It can also cause nerve damage, eventually leading to paralysis. Up to 40% to 50% of those who don't get treated can die.
Prevention

Preventing diphtheria depends almost completely on immunizing children with the diphtheria/tetanus/pertussis (DTP or DTaP) vaccine and non-immunized adults with the diphtheria/tetanus vaccine (DT). Most cases of diphtheria occur in people who haven't received the vaccine at all or haven't received the entire course.

The immunization schedule calls for:

* DTaP vaccines at 2, 4, and 6 months of age
* booster dose given at 12 to 18 months
* booster dose given again at 4 to 6 years
* booster shots given every 10 years after that to maintain protection

Although most children tolerate it well, the vaccine sometimes causes mild side effects such as redness or tenderness at the injection site, a low-grade fever, or general fussiness or crankiness. Severe complications, such as an allergic reaction, are rare.
Contagiousness

Diphtheria is highly contagious. It's easily passed from the infected person to others through sneezing, coughing, or even laughing. It can also be spread to others who pick up tissues or drinking glasses that have been used by the infected person.

People who have been infected by the diphtheria bacteria can infect others for up to 4 weeks, even if they don't have any symptoms. The incubation period (the time it takes for a person to become infected after being exposed) for diphtheria is 2 to 4 days, although it can range from 1 to 6 days.
Treatment

Children and adults with diphtheria are treated in a hospital. After a doctor confirms the diagnosis through a throat culture, the infected person receives a special anti-toxin, given through injections or through an IV, to neutralize the diphtheria toxin already circulating in the body, as well as antibiotics to kill the remaining diphtheria bacteria.

If the infection is advanced, people with diphtheria may need a ventilator to help them breathe. In cases in which the toxins may have spread to the heart, kidneys, or central nervous system, patients may need intravenous fluids, oxygen, or heart medications.

A person with diphtheria must also be isolated. Family members (as well as others who spend a lot of time with the person with diphtheria) who haven't been immunized, or who are very young or elderly, must be protected from contact with the patient.

When someone is diagnosed with diphtheria, the doctor will notify the local health department and will take steps to treat everyone in the household who may have been exposed to the bacteria. This will include assessment of immune status, throat cultures, and booster doses of the diphtheria vaccine. They will also receive antibiotics as a precaution.

Immediate hospitalization and early intervention allow most patients to recover from diphtheria. After the antibiotics and anti-toxin have taken effect, someone with diphtheria will need bed rest for a while (4 to 6 weeks, or until full recovery). Bed rest is particularly important if the person's heart has been affected by the disease. Myocarditis, or inflammation of the heart muscle, can be a complication of diphtheria.

Those who have recovered should still receive a full course of the diphtheria vaccine to prevent a recurrence because contracting the disease doesn't guarantee lifetime immunity.
When to Call Your Child's Doctor

Call your doctor immediately if you or your child has symptoms of diphtheria, if you observe symptoms in someone else, if anyone in your family is exposed to diphtheria, or if you think that you or a family member is at risk. It's important to remember, though, that most throat infections are not diphtheria, especially in countries that have routine immunizations against it.

If you're not sure if your child has been vaccinated against diphtheria, make an appointment. Also make sure your own booster immunizations are current. International studies have shown that a significant percentage of adults over 40 years of age aren't adequately protected against diphtheria and tetanus.

whooping cough

Whooping cough in a recognizable form evolves over a period of 2 weeks. It usually starts as a sore throat with a mild feeling of tiredness and being unwell, that within 2 or 3 days turns into a (usually) dry, intermittent "ordinary" cough. This persists, but may wax and wane over the next 7 to 10 days by which time the cough may become a little productive of small amounts of sticky clear phlegm, and occasional intense bouts of choking coughing start to occur.

Fever is usually limited to the first week and is only mild. There may be a runny nose like a cold in the early stages. After the first 2 weeks, the characteristics described below are redominant.

Major Symptoms (usually from 2 weeks onwards). Attacks of a choking cough that lasts from 1 to 2 minutes, often with vomiting, severe facial congestions and a feeling or appearance of suffocation. Between these attacks of coughing the sufferer appears and usually feels perfectly well.These choking attacks of coughing happen as little as twice a day or as many as fifty. Between attacks ('paroxysms' is the technical name) the sufferer may not cough at all.'Whooping' is a noise that comes from the voice box after a paroxysm when the sufferer is suddenly able to take a breath in again.

Only about 50% of whooping cough sufferers 'whoop' but this is where the name comes from. Sometimes the patient stops breathing after a severe bout of coughing, long enough to go blue. Occasionally the patient faints as well. Recovery is usually rapid however, and back to normal within a couple of minutes

Whooping cough lasts at least 3 weeks and can frequently go on for 3 months or even longer. I am told that in China it is called the 100 day cough.

Late symptoms. Whooping cough resolves by a slow reduction in the number of choking attacks. From the time the attacks start to reduce in number, to the time they finish, it may be roughly from 2 weeks to 2 months or more. The average case of whooping cough lasts about 7 weeks. But for people with whooping cough visiting this site, it is likely to last longer, because only more severe cases are likely to get hereImportant points

The crucial point for clinical diagnosis is attacks of severe choking cough separated by long intervals of NO COUGHING AT ALL. There is immense variation in severity and duration of the illness.MOST CASES GO UNDIAGNOSED BECAUSE THE PHYSICIAN NEVER HEARS THE PATIENT COUGH AND CANNOT BELIEVE IT IS AS SEVERE AS HE/SHE IS BEING TOLD. AND LISTENING WITH A STETHOSCOPE INDICATES NORMAL LUNGS IN WHOOPING COUGH!

Mycobacterium Tuberculosis

General Features

Mycobacterium tuberculosis is the organism that is the causative agent for tuberculosis (TB). There are other "atypical" mycobacteria such as M. kansasii that may produced a similar clincal and pathologic appearance of disease. M. avium-intracellulare (MAI) seen in immunocompromised hosts (particularly in persons with AIDS) is not primarily a pulmonary infection in terms of its organ distribution (mostly in organs of the mononuclear phagocyte system).

Tuberculosis is becoming a world-wide problem. War, famine, homelessness, and a lack of medical care all contribute to the increasing incidence of tuberculosis among disadvantaged persons. Since TB is easily transmissible between persons, then the increase in TB in any segment of the population represents a threat to all segments of the population. This means that it is important to institute and maintain appropriate public health measures, including screening, vaccination (where deemed of value), and treatment. A laxity of public health measures will contribute to an increase in cases. Failure of adequate treatment promotes the development of resistant strains of tuberculosis.
Patterns of Infection

There are two major patterns of disease with TB:

* Primary tuberculosis: seen as an initial infection, usually in children. The initial focus of infection is a small subpleural granuloma accompanied by granulomatous hilar lymph node infection. Together, these make up the Ghon complex. In nearly all cases, these granulomas resolve and there is no further spread of the infection.
* Secondary tuberculosis: seen mostly in adults as a reactivation of previous infection (or reinfection), particularly when health status declines. The granulomatous inflammation is much more florid and widespread. Typically, the upper lung lobes are most affected, and cavitation can occur.

When resistance to infection is particularly poor, a "miliary" pattern of spread can occur in which there are a myriad of small millet seed (1-3 mm) sized granulomas, either in lung or in other organs.

Dissemination of tuberculosis outside of lungs can lead to the appearance of a number of uncommon findings with characteristic patterns:

Skeletal Tuberculosis: Tuberculous osteomyelitis involves mainly the thoracic and lumbar vertebrae (known as Pott's disease) followed by knee and hip. There is extensive necrosis and bony destruction with compressed fractures (with kyphosis) and extension to soft tissues, including psoas "cold" abscess.

Genital Tract Tuberculosis: Tuberculous salpingitis and endometritis result from dissemination of tuberculosis to the fallopian tube that leads to granulomatous salpingitis, which can drain into the endometrial cavity and cause a granulomatous endometritis with irregular menstrual bleeding and infertility. In the male, tuberculosis involves prostate and epididymis most often with non-tender induration and infertility.

Urinary Tract Tuberculosis: A "sterile pyuria" with WBC's present in urine but a negative routine bacterial culture may suggest the diagnosis of renal tuberculosis. Progressive destruction of renal parenchyma occurs if not treated. Drainage to the ureters can lead to inflammation with ureteral stricture.

CNS Tuberculosis: A meningeal pattern of spread can occur, and the cerebrospinal fluid typically shows a high protein, low glucose, and lymphocytosis. The base of the brain is often involved, so that various cranial nerve signs may be present. Rarely, a solitary granuloma, or "tuberculoma", may form and manifest with seizures.

Gastrointestinal Tuberculosis: This is uncommon today because routine pasteurization of milk has eliminated Mycobacterium bovis infections. However, M. tuberculosis organisms coughed up in sputum may be swallowed into the GI tract. The classic lesions are circumferential ulcerations with stricture of the small intestine. There is a predilection for ileocecal involvement because of the abundant lymphoid tissue and slower rate of passage of lumenal contents.

Adrenal Tuberculosis: Spread of tuberculosis to adrenals is usually bilateral, so that both adrenals are markedly enlarged. Destruction of cortex leads to Addison's disease.

Scrofula: Tuberculous lymphadenitis of the cervical nodes may produce a mass of firm, matted nodes just under the mandible. There can be chronic draining fistulous tracts to overlying skin. This complication may appear in children, and Mycobacterium scrofulaceum may be cultured.

Cardiac Tuberculosis: The pericardium is the usual site for tuberculous infection of heart. The result is a granulomatous pericarditis that can be hemorrhagic. If extensive and chronic, there can be fibrosis with calcification, leading to a constrictive pericarditis.

The following images illustrate gross pathologic findings with tuberculosis:

1. Ghon complex in lung, gross.
2. Ghon complex in lung, closer view, gross.
3. Cavitary tuberculosis in lung, gross.
4. Cavitary tuberculosis in lung, closer view, gross.
5. Cavitary tuberculosis in lung, florid, gross.
6. Miliary tuberculosis in lung, gross.
7. Miliary tuberculosis in lung, closer view, gross.

Microscopic Findings

Microscopically, the inflammation produced with TB infection is granulomatous, with epithelioid macrophages and Langhans giant cells along with lymphocytes, plasma cells, maybe a few PMN's, fibroblasts with collagen, and characteristic caseous necrosis in the center. The inflammatory response is mediated by a type IV hypersensitivity reaction. This can be utilized as a basis for diagnosis by a TB skin test. An acid fast stain (Ziehl-Neelsen or Kinyoun's acid fast stains) will show the organisms as slender red rods. An auramine stain of the organisms as viewed under fluorescence microscopy will be easier to screen and more organisms will be apparent. The most common specimen screened is sputum, but the histologic stains can also be performed on tissues or other body fluids. Culture of sputum or tissues or other body fluids can be done to determine drug sensitivities.

1. Granulomas in lung, low power microscopic.
2. Granuloma with caseous necrosis, high power microscopic.
3. Granuloma with epithelioid macrophages and a Langhans giant cell, high power microscopic.
4. Granulomatous endometritis, high power microscopic.
5. Ziehl-Neelsen acid fast stain, microscopic, AFB stain.
6. Auramine stain, M. tuberculosis, fluorescence microscopy.

Tuberculin Skin Testing

Skin testing for tuberculosis is useful in countries where the incidence of tuberculosis is low, and the health care system works well to detect and treat new cases. In countries where BCG vaccination has been widely used, the TB skin test is not useful, because persons vaccinated with BCG will have a positive skin test.

The TB skin test is based upon the type 4 hypersensitivity reaction. If a previous TB infection has occurred, then there are sensitized lymphocytes that can react to another encounter with antigens from TB organisms. For the TB skin test, a measured amount (the intermediate strength of 5 tuberculin units, used in North America) of tuberculin purified protein derivative (PPD) is injected intracutaneously to form a small wheal, typically on the forearm. In 48 to 72 hours, a positive reaction is marked by an area of red induration that can be measured by gentle palpation (redness from itching and scratching doesn't count). Reactions over 10 mm in size are considered positive in non-immunocompromised persons.

Repeated testing may increase the size of the reaction (induration), but repeated TB skin testing will not lead to a positive test in a person not infected by TB. Anergy, or absence of PPD reactivity in persons infected with TB, can occur in immunocompromised persons, or it may even occur in persons newly infected with TB, or in persons with miliary TB.

1. Injecting PPD intracutaneously, gross.
2. A properly placed TB skin test, gross.
3. A positive TB skin test, gross.

Mumps

Mumps is a disease caused by a virus that usually spreads through saliva and can infect many parts of the body, especially the parotid salivary glands. These glands, which produce saliva for the mouth, are found toward the back of each cheek, in the area between the ear and jaw. In cases of mumps, these glands typically swell and become painful.

The disease has been recognized for several centuries, and medical historians argue over whether the name "mumps" comes from an old word for "lump" or an old word for "mumble."

Mumps was common until the mumps vaccine was licensed in 1967. Before the vaccine, more than 200,000 cases occurred each year in the United States. Since then the number of cases has dropped to fewer than 1,000 a year, and epidemics have become fairly rare. As in the prevaccine era, most cases of mumps are still in children ages 5 to 14, but the proportion of young adults who become infected has been rising slowly over the last two decades. Mumps infections are uncommon in children younger than 1 year old.

After a case of mumps it is very unusual to have a second bout because one attack of mumps almost always gives lifelong protection against another. However, other infections can also cause swelling in the salivary glands, which might lead a parent to mistakenly think a child has had mumps more than once.
Signs and Symptoms

Cases of mumps may start with a fever of up to 103 degrees Fahrenheit (39.4 degrees Celsius), as well as a headache and loss of appetite. The well-known hallmark of mumps is swelling and pain in the parotid glands, making the child look like a hamster with food in its cheeks. The glands usually become increasingly swollen and painful over a period of 1 to 3 days. The pain gets worse when the child swallows, talks, chews, or drinks acidic juices (like orange juice).

Both the left and right parotid glands may be affected, with one side swelling a few days before the other, or only one side may swell. In rare cases, mumps will attack other groups of salivary glands instead of the parotids. If this happens, swelling may be noticed under the tongue, under the jaw, or all the way down to the front of the chest.

Mumps can lead to inflammation and swelling of the brain and other organs, although this is not common. Encephalitis (inflammation of the brain) and meningitis (inflammation of the lining of the brain and spinal cord) are both rare complications of mumps. Symptoms appear in the first week after the parotid glands begin to swell and may include: high fever, stiff neck, headache, nausea and vomiting, drowsiness, convulsions, and other signs of brain involvement.

Mumps in adolescent and adult males may also result in the development of orchitis, an inflammation of the testicles. Usually one testicle becomes swollen and painful about 7 to 10 days after the parotids swell. This is accompanied by a high fever, shaking chills, headache, nausea, vomiting, and abdominal pain that can sometimes be mistaken for appendicitis if the right testicle is affected. After 3 to 7 days, testicular pain and swelling subside, usually at about the same time that the fever passes. In some cases, both testicles are involved. Even with involvement of both testicles, sterility is only a rare complication of orchitis.

Additionally, mumps may affect the pancreas or, in females, the ovaries, causing pain and tenderness in parts of the abdomen.

In some cases, signs and symptoms of mumps are so mild that no one suspects a mumps infection. Doctors believe that about one in three people may have a mumps infection without symptoms.
Contagiousness

The mumps virus is contagious and spreads in tiny drops of fluid from the mouth and nose of someone who is infected. It can be passed to others through sneezing, coughing, or even laughing. The virus can also spread to other people through direct contact, such as picking up tissues or using drinking glasses that have been used by the infected person.

People who have mumps are most contagious from 2 days before symptoms begin to 6 days after they end. The virus can also spread from people who are infected but have no symptoms.
Prevention

Mumps can be prevented by vaccination. The vaccine can be given alone or as part of the measles-mumps-rubella (MMR) immunization, which is usually given to children at 12 to 15 months of age. A second dose of MMR is generally given at 4 to 6 years of age. As is the case with all immunization schedules, there are important exceptions and special circumstances.
If they haven't already received them, students who are attending colleges and other post-high school institutions should be sure they have had two doses of the MMR vaccine. During a measles outbreak, your doctor may recommend additional shots of the vaccine, if your child is 1 to 4 years old. Your child's doctor will have the most current information.
Incubation

The incubation period for mumps can be 12 to 25 days, but the average is 16 to 18 days.
Duration

Children usually recover from mumps in about 10 to 12 days. It takes about 1 week for the swelling to disappear in each parotid gland, but both glands don't usually swell at the same time.
Professional Treatment

If you think that your child has mumps, call your child's doctor, who can confirm the diagnosis and work with you to monitor your child's progress and watch for any complications. The doctor can also notify the health authorities who keep track of childhood immunization programs and mumps outbreaks.

Because mumps is caused by a virus, it cannot be treated with antibiotics.

At home, monitor and keep track of your child's temperature. You can use nonaspirin fever medications such as acetaminophen or ibuprofen to bring down a fever. These medicines will also help relieve pain in the swollen parotid glands. Unless instructed by your child's doctor, aspirin should not be used in children with viral illnesses because the use of aspirin in such cases has been associated with the development of Reye syndrome, which can lead to liver failure and death.

You can also soothe your child's swollen parotid glands with either warm or cold packs. Serve a soft, bland diet that does not require a lot of chewing and encourage your child to drink plenty of fluids. Avoid serving tart or acidic fruit juices (like orange juice, grapefruit juice, or lemonade) that make parotid pain worse. Water, decaffeinated soft drinks, and tea are better tolerated.

When mumps involves the testicles, the doctor may prescribe stronger medications for pain and swelling and provide instructions on how to apply warm or cool packs to soothe the area and how to provide extra support for the testicles.

A child with mumps doesn't need to stay in bed, but may play quietly. Ask your doctor about the best time for your child to return to school.
When to Call Your Child's Doctor

Call your child's doctor if you suspect that your child has mumps. If your child has been diagnosed with mumps, keep track of your child's temperature and call the doctor if it climbs above 101 degrees Fahrenheit (38.3 degrees Celsius).

Because mumps can also involve the brain and its membranes, call the doctor immediately if your child has any of the following: stiff neck, convulsions (seizures), extreme drowsiness, severe headache, or changes of consciousness. Watch for abdominal pain that can mean involvement of the pancreas in either sex or involvement of the ovaries in girls. In boys, watch for high fever with pain and swelling of the testicles.

MEASLES

What is measles?

Measles is one of the most contagious viral diseases. It is caused by paramyxo virus and is the most unpleasant and the most dangerous of the children's diseases that result in a rash. This is due to the complications of the disease.

How is measles transmitted?

* Droplets transfer the infections. Although the sick person may be in isolation, the disease may still spread from room to room.

* Anybody who has not already had measles can be infected.

* Infants up to four months of age will not be infected if their mother has had measles herself because they will be protected by her antibodies.

* The incubation period - the time between infection and the outbreak of the condition - is usually one to two weeks.

* Patients are infectious from four days before the onset of the rash until five days after it appears.

What are the symptoms of measles?

After about 14 days the following symptoms start showing:

* a fever at about 39ºC.

* a cold.

* coughing, possibly with a barking cough.

* sore throat - the lymph nodes in the throat may swell.

* reddish eyes.

* sensitivity to light.

* greyish spots, the size of grains of sand may appear in the mucous membrane of the mouth just around the molar teeth. These are called Koplik's spots and can be seen before the rash appears.

* after three to four days the temperature may fall, although it can run high again when the rash appears.

* the rash usually begins around the ears and spreads to the body and the legs within a day or two.

* at first the spots are very small - a couple of millimetres - but they double in size quickly and begin to join together.

* the spots are a clear red colour.

* the temperature, which may run as high as 40ºC, may stay that high for a couple of days. Then it disappears together with the rash, which may leave some brown spots.

* after a week the child will be fit again.

Children who have had measles cannot return to school or childcare before they recover and the temperature is gone.

The doctor should give children under the age of one who are exposed to the disease an immunity injection within five days.

In the UK all children between the age of 12 and 15 months are offered the MMR vaccination, which will protect them from measles, mumps and rubella.

How are measles treated ?

The treatment is to stay in bed in a cool room without any bright lights. Medicines for coughing and reducing the temperature should only be given after consulting a GP.

Future prospects

The doctor should be consulted immediately if the condition of the child gets worse or the temperature stays high.

The doctor must make sure there are no further complications such as:

* pneumonia

* inflammation of the middle ear (otitis media)

* inflammation of the nervous system. Luckily, this seldom happens and is the exception rather than the rule.

Once a person has had measles, they can never catch it again as the disease gives lifelong immunity.

Measles and pregnancy

If you are planning a pregnancy, you should make sure that you have a measles vaccination unless you have had the disease in the past.

Having measles during a pregnancy can result in an infection of the unborn child and may in the worst case result in the death of the baby.

If in doubt you should consult your GP in order to get the MMR vaccine. This vaccine cannot be given during pregnancy.

The recent large rise in the number of cases of measles in the UK has been directly linked to a fall in the number of children receiving the MMR vaccine.

RUBELLA VIRUS

German measles is a mild viral illness caused by the rubella virus. It causes a mild feverish illness associated with a rash, and aches in the joints when it affects adults. The major reason for any attention being devoted to the eradication of this condition is the nasty effects that it has on the unborn baby (known as a fetus), when a pregnant woman catches it in early pregnancy.
Children are not usually affected too badly, and often the first manifestation is the rash. This is a fine, pink rash spreading from the forehead and face downwards. The rash may last for 1 to 5 days. There are often some of the glands (lymph nodes) enlarged, especially behind the ears and on the back of the head. Adults often feel more unwell before the rash appears, and may have pains in the joints rather like arthritis.
The cause is the rubella virus. The incubation period, from exposure to the appearance of the rash, is usually 14 to 21 days.

If a pregnant woman thinks she has been exposed to German Measles, she should first of all check with her midwife or her doctor on her rubella status, ie whether the blood test, taken early in pregnancy shows her to be immune to rubella. In that case, she need not worry. You will not catch German Measles if you are immune, and if you do not catch it, your fetus cannot be affected, even if you come into contact with someone who has German Measles.

If she has had previous children then it is likely that she will be known to have been immune at that time, or will have been inoculated after the last pregnancy. If in doubt ask. Your doctor will want to do blood tests to ascertain whether you have caught German Measles or not, or are already immune. Your baby is not at risk if you do not catch the virus.

There is an injection (immunoglobulin) which can reduce the likelihood of actually coming out with the obvious German Measles, but it does not prevent an infection in someone who is not immune who has come into contact with the disease, and is not recommended in the UK as a way of protecting susceptible pregnant women who have come into contact with rubella.

In these cases, where a non-immune woman in the early stages of pregnancy catches rubella, she would normally be counselled regarding termination of pregnancy. If this would not be considered, for medical or moral reasons, then she would be offered the immunoglobulin, as soon as possible after exposure to rubella. There is thought to be a logical argument that cutting down the severity of an attack will reduce the likelihood of fetal damage occurring.

Prevention

Up until fairly recently, in the UK, girls were inoculated against rubella in their early teens. There is now a vaccine, which, in the UK, is given at at 12 to 15 months, along with vaccines for meales and . mumps.A booster is given before starting school. This vaccine is known as mmr.

Actually having the disease confers lifelong immunity, and the vaccine is supposed to have a similar effect. If the worldwide uptake of any vaccine is high enough, the actual disease can be eradicated eg Smallpox.

CMV

Infection with cytomegalovirus (CMV), a member of the herpes virus family, is very common. Between 50% and 85% of people in the United States have had a CMV infection by the time they are 40 years old, according to the Centers for Disease Control and Prevention (CDC).

Children typically become infected with the virus in early childhood, especially those in child-care and preschool settings. CMV infections are rarely serious in otherwise healthy children and adults; they usually cause only mild symptoms, if any. When symptoms do appear, they are similar to those seen in mononucleosis ("mono") and only last a few weeks.

CMV is mainly a problem for certain high-risk groups, including:

• unborn babies whose mothers become infected with CMV during the pregnancy
• children or adults whose immune systems have been weakened by disease or drug treatment, such as organ transplant recipients or people infected with HIV

Once a person has had a CMV infection, the virus usually lies dormant (or inactive) in the body, but it can be reactivated. The virus is more likely to be reactivated – and cause serious illness – in people who have weakened immune systems due to illness.

Symptoms of CMV Infections

The symptoms of a CMV infection vary depending upon the age and health of the person who is infected, and how the infection occurred.

Infants who are infected before birth usually show no symptoms of a CMV infection after they are born, although some of these infants can develop hearing, vision, neurologic, and developmental problems over time. In a few cases, there are symptoms at birth, which can include premature delivery, being small for gestational age, jaundice, enlarged liver and spleen, microcephaly (small head), seizures, rash, and feeding difficulties. These infants are also at high risk for developing hearing, vision, neurologic, and developmental problems.

Newborns can also contract CMV infection during or soon after birth by passing through the birth canal of an infected mother, consuming breast milk from a mother with the virus, or receiving a transfusion of blood donated by a person infected with CMV. Most of these infants show no symptoms of CMV infection, however, a few may develop pneumonia or other symptoms. Premature and ill full-term infants who are infected soon after birth are also at risk for neurologic and developmental problems over time.

Although CMV infections that occur in children after the newborn period usually don’t cause significant illness, some infants and young children may develop pneumonia, hepatitis (inflammation of the liver), or a rash.

Older children and teens who become infected with the virus may have mononucleosis-like symptoms, including fatigue, muscle aches, headache, fever and enlarged liver and spleen. These symptoms are generally mild, and usually last only 2-3 weeks.

In people who have received organ transplants, or in people whose immune systems are weakened, CMV can cause serious infections. In people who have AIDS or HIV, CMV infection may involve the lungs, nervous system, gastrointestinal tract, and the eye, sometimes causing blindness.

How Long Do The Symptoms Last?

If symptoms of CMV do appear, how long they last varies depending on how the infection occurs and the age and general health of the patient. For example, serious CMV infections before birth may cause developmental problems that affect a child for a lifetime. On the other hand, infection in teens may last only 2 to 3 weeks and cause no lasting problems.

How Does CMV Spread?

In the United States, about 1% of infants are infected with CMV before birth - usually only if the mother has developed a first-time CMV infection during pregnancy. As discussed above, an infected mother can pass the virus to her child before, during, or after birth.

Any person with a new or past CMV infection can transmit the virus to others, even if he or she isn’t showing any symptoms. But transmission usually requires fairly close contact; the virus can be spread through saliva, breast milk, vaginal fluids, semen, urine, and stool. The virus can also be present in blood products and donated organs, causing infection after a blood transfusion or organ transplantation.

Among kids, the virus is commonly spread in child-care centers or preschool settings, where it passes easily through indirect contact, especially though contaminated toys. Children who are infected may then spread the infection to their families.

Diagnosing and Treating CMV

In serious cases of CMV infection, doctors can make the diagnosis by detecting the virus in a cultured sample taken from a sick person's throat, urine, blood, or other body tissues or fluid. Blood is also drawn at different time intervals to measure levels of certain antibodies. These antibodies are part of the immune system's response to a CMV infection, and they can signal that an active CMV infection exists. Special viral DNA-detecting tests are also sometimes used to diagnosis CMV infection.

Currently, there is no specific treatment available or recommended for otherwise healthy people with CMV infection.

In patients where CMV infection can be life-threatening (newborn infants, organ-transplant patients, and people being treated for cancer or who have immune disorders such as AIDS), serious CMV infections may be treated with intravenous (IV) antiviral medication, usually in a hospital. Oral antiviral medication may also be used at home once the infection is under control and the patient is stable. Because these antiviral medicines may have serious side effects, doctors use them with great caution, especially in children.

In bone-marrow transplant patients, CMV-immune globulin (CMV-IVIG) and the anti-viral drug ganciclovir given intravenously can be used to fight CMV infections.

Preventing CMV Infections

Currently, there is no vaccine to prevent CMV infection. For those who have close contact with children, especially pregnant women or women who might become pregnant, handwashing is effective at reducing the risk of infection from exposure to CMV. Not sharing eating utensils with young children and avoiding kissing or intimate contact with CMV-positive individuals is also important.

A mother who has CMV infection shouldn’t stop breastfeeding, as the benefits of breastfeeding are believed to outweigh the risks of passing CMV to the infant, and the infant is unlikely to develop any symptoms if infected.

For organ-transplant patients who are at risk of getting CMV from a transplanted organ, preventive therapies are available. Blood banks have certain screening and processing procedures that help to prevent CMV from being passed in blood products.

When to Call Your Child's Doctor

Call your child's doctor if your child has any of these or other “mono-like” symptoms:

• fever that lasts for several days
• unusual or extreme tiredness
• muscle aches
• headache

If you are pregnant, ask your doctor about your risk for CMV infection and about how you can help protect your developing baby from CMV infection before birth.

If your child has had an organ transplant or has HIV, AIDS, cancer, or any disease that affects the immune system, he or she is at special risk of CMV infection. Keep in close contact with your child's doctor about signs and symptoms to watch for..