The Shingles-Chicken Pox Connection

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One Virus Causes Both

          Several recent questions from our readers made me realize that confusion abounds when it comes to shingles and chicken pox and the connection between the two.  Chicken pox (varicella) was once a right of passage for every child born before the varicella vaccine became available in the United States in 1995.  It is so highly infectious that very few escaped into adulthood without contracting chicken pox, which then conferred immunity to the virus that causes it.  In fact, more than 90% of adults test positive for immunity to varicella from exposure in childhood.  It is now recommended that children receive the varicella vaccine, which contains live attenuated virus, in two doses, the first between 12 and 15 months and the second between 4 and 6 years of age.  Children who receive the vaccination for chicken pox will either avoid contracting the infection or have a milder case of shorter duration.  Even more importantly they can avoid the rare but serious complications that sometimes occur. 

          For those who have had either chicken pox or the varicella vaccine to prevent it, the virus lies dormant in the sensory nerve ganglia near the spine where it is kept under control by the immune system.  The latent virus can reassert itself at a later time, often many years later, in the form of a painful rash known as shingles (herpes-zoster), if the immune system loses its ability to keep it under control.  It is important to understand, then, that both chicken pox (varicella) and shingles (herpes zoster) are caused by the same human herpesvirus known as varicella-zoster. 

Chicken Pox 

          In unimmunized populations, chicken pox is most common in children under the age of 12.  It is an acute illness with a characteristic itchy rash often accompanied by flu-like symptoms, including fever, headache and abdominal pain.  The rash occurs 10 to 20 days after exposure and begins on the face, scalp and trunk first, then spreading out to the extremities.  The rash begins as crops of pimples that become fluid filled vesicles which crust over within about a week.  Patients with chicken pox are contagious one to two days before the rash appears and until all the lesions have crusted over.  It is spread by respiratory secretions or direct contact with fluid from the vesicles. 

          Serious complications include bacterial skin infections from scratching the lesions, encephalitis, cerebellar ataxia and pneumonia.  Newborns, older children and adults, as well as those with compromised immune systems, are at greatest risk of complications.  If a women who has not had chicken pox or the varicella vaccine contracts chicken pox during pregnancy, her child could be at risk of having birth defects.  Anyone who has not had chicken pox or the varicella vaccine can catch chicken pox from someone with an active case of shingles, but cannot contract shingles itself.  Shingles can only occur from a reactivation of the varicella-zoster virus in someone who has previously had chicken pox or the varicella vaccine. 

Shingles 

          Shingles or herpes zoster occurs when immunity wanes due to aging, stress, or diseases such as malignancy or as a result of therapy that suppresses the immune system.  It is more likely to occur after the age of 50 and approximately 30% of people will develop shingles sometime during their lifetime and usually only once.  Shingles only occurs in those who have had either chicken pox or the varicella vaccine.  When the chicken pox virus is reactivated in the sensory nerve ganglia it results in a painful, burning rash in the distribution of that nerve.  The rash is therefore located on only one side of the body often appearing as a narrow band or strip extending from the spine around to the front.  While the rash is most often in the trunk area, other areas can be involved. 

          When the latent virus is reactivated in the trigeminal nerve supplying the face, severe involvement of the eye can occur, sometimes leading to blindness.  Often before the rash appears the patient will experience intense itching and pain in that area.  The lesions begin as a red rash progressing to blisters which usually crust over within a week to 10 days.  Patients with shingles can also experience malaise, fever, chills and headache.  One of the most unpleasant complications of shingles is known as post-herpetic neuralgia, a condition where the pain persists after the rash has resolved. 

Prevention and Treatment 

          Chicken pox:  Even after completing the two recommended doses of the varicella vaccine, it is still possible to get chickenpox.  The disease in such cases is usually milder.  Older children between 7 and 12 years of age who have not received the vaccine should receive two catch up doses at least three months apart.  It is also recommended that individuals 13 years and older who have never had chicken pox or the varicella vaccine receive two doses of the vaccine at least 28 days apart.  For children who develop chickenpox, keeping the fingernails trimmed may help prevent bacterial skin infection caused by scratching the itchy lesions.  Oral antihistamines may also help the itching.  Antiviral medications, such as acyclovir, may be used in patients with eczema, asthma or immunosuppression, but are only helpful if started within 24 hours of the development of the rash.  Tylenol (acetaminophen) may be used for fever and pain, but aspirin should never be used in children because of the possibility of Reye’s syndrome.  Because the infection is so contagious, children with chicken pox should be kept out of school until all the lesions have crusted over, usually about ten days from onset of symptoms. 

          Shingles:  Shingles can also be treated with antiviral medications if started within 24 hours of the onset of symptoms.  Several other medications are available to specifically help control the pain of post-herpetic neuralgia.  The zoster vaccine has been recommended for individuals older than 60 years by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) recently approved the use of the vaccine in individuals 50 and older.  Studies have shown that the incidence of shingles is about 50% lower in individuals who have been vaccinated and the incidence of post-herpetic neuralgia is about 67% lower.  Your personal physician should be able to answer any questions you have about chickenpox, shingles or the vaccines used to prevent either illness.

  

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Ringworm or Tinea

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The Fungus Amungus 

          Ringworm or Tinea (a Latin word meaning a growing worm) is one of the most common skin diseases of man.  It is actually caused by a fungus of the dermatophyte (a Greek word meaning skin plant) group, usually of the genus Trichophyton, Epidermophyton or Microsporum.  These fungi have the ability to infect and flourish on the dead keratin that is found in the top layer of skin, hair or nails.  All forms of Tinea (pronounced tih-nee-uh) are contagious and can spread from one infected area of your body to another or can be transmitted through person to person contact or by contact with soil, cats or dogs.  Tinea occurs worldwide in all age groups, but is particularly common in children.  Next to acne, Tinea is the most common skin disease reported in the United States and it is estimated that there is a 10 to 20% chance that each human will acquire a Tinea skin infection sometime during their lifetime.  Areas of the body characterized by moisture, friction and warmth are particularly susceptible, making obesity a predisposing factor. 

Symptoms and Diagnosis 

          Because some forms of Tinea are manifested by a circular lesion with central clearing surrounded by a well-demarcated, advancing, red, scaly, elevated border it has come to be known as ‘ringworm’, although it is not caused by a worm at all.  While the various forms of Tinea generally cause superficial skin infections which are itchy, the appearance and symptoms depend on the site of infection.  Your health care provider can identify the typical branching filaments or hyphae of Tinea by taking a scraping of the skin lesion and looking at a potassium hydroxide wet mount under the microscope.  For recalcitrant infections and infections requiring oral medications a culture is often taken, as well, to confirm the diagnosis.

A Lesson in Anatomy (and Latin!) 

          The appearance, symptoms and treatment of Tinea vary depending on the area of the body that is infected, with the various forms named for the body part involved: 

Tinea Capitis (from the Latin caput meaning head)

          This infection can appear in several different forms on the scalp, from a dandruff-like lesion to a boggy mass known as a Kerion.  It can cause mild to extensive hair loss and may be transmitted by sharing hair combs and brushes.  In addition to microscopic examination and culture it may also be identified by Wood light examination.  Treatment is with oral antifungal medication and patients must take pills for 4 to 6 weeks under the close supervision of a health care provider. 

Tinea Corporis (from the Latin corpus meaning body)

          This form is manifested by the classic circular lesion on the face, trunk or limbs.  It often responds to topical application of antifungal medications, but extensive cases may require oral medications.  Tinea gladiatorum is an interesting form of this infection seen in wrestlers, where skin to skin contact is extensive. 

Tinea Cruris (from the Latin crus meaning leg) Jock Itch

          One of the most common forms of Tinea, it occurs in the groin area and upper thighs.  The margins of the lesion are sharp and generally symmetrical on both sides.  It occurs most often in adolescent and adult males and can be extremely itchy.  It often occurs in association with Tinea pedis (athlete’s foot) and can usually be treated with topical medications.  Keeping the area dry and wearing loose fitting underwear is also important. 

Tinea Manuum (from the Latin manus meaning hand)

          In this form of Tinea one or both hands are infected, causing areas of peeling, dryness and itching, generally on the palms.  It is often seen in association with Tinea pedis.  It can usually be resolved by application of topical antifungal agents. 

Tinea Pedis (from the Latin ped meaning foot) Athlete’s Foot

          Probably the most common of the dermatophyte infections, this form occurs most commonly in men age 20 to 40 years.  It is characterized by a whitish, macerated area between the toes and occasionally on the sides and top of the foot which can be extremely itchy.  It is usually acquired by walking barefoot where someone else with athlete’s foot has walked.  Occlusive footwear and frequent use of gyms, locker rooms and pools are predisposing factors.  Topical antifungal agents are usually effective, but recurrent cases sometimes require oral medications. 

Tinea Unguium (from the Latin unguis meaning nail)

          Tinea is only one type of infection that can involve the nails, usually the toe nails.  It occurs in adults more often than children.  Several factors, including age, diabetes, poor circulation, poorly fitting footwear and sports participation increase one’s chance of acquiring this infection.  The nail becomes brittle, thickened and discolored and is often painful.  Successful treatment generally requires oral antifungal medications. 

Treatment and Prevention 

          Most forms of Tinea can be treated with topical antifungal agents with the notable exceptions of Tinea capitis and Tinea unguium which usually require oral medications.  Treatment can take up to 4 to 6 weeks and sometimes longer.  Sometimes a topical corticosteroid is used together with an antifungal agent to reduce inflammation; however, steroids should never be used alone, as they may make the fungal infection worse.  Because all forms of Tinea are contagious and are acquired by direct contact, there are several steps that can be taken to help prevent infection.  Sharing combs, hair brushes, head gear, towels, and clothing should be avoided.  Wearing flip-flops in the locker room and drying the feet thoroughly after showering can help prevent athlete’s foot.  Because the fungi causing Tinea thrive in warm, moist areas, it is important to keep parts of the body where skin comes into contact with skin dry, such as the groin, under arms, and under the breasts.  It may also help to wear loose fitting clothing and to wash sheets and bed clothing on a daily basis until the infection is resolved.  Tinea can be confused with other skin diseases, including intertrigo, seborrheic dermatitis, psoriasis, irritant and allergic dermatitis and superficial bacterial infections.  Your health care provider can distinguish between the various skin rashes caused by these entities and prescribe the correct treatment for you.

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Celebrating Our First Anniversary

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          Since publishing our first article one year ago this week, Health Matters has slowly and steadily built up a loyal readership, including many visitors from around the world.  Those seeking information about common medical conditions know they can trust Health Matters to provide accurate, up-to-date information presented in a well organized format and understandable language.  Information is provided from the point of view of a family physician with an occasional editorial comment when appropriate.  

          This past year we’ve provided articles on such varied topics as arthritis, liver disease, and swimmer’s ear.  In the coming year, watch for new articles covering subjects that our readers have requested, such as skin disease, shingles, gall bladder disease, and colonoscopy.  In addition to continuing the quality content that we have provided in the past, our goal for the coming year will be to increase the engagement of our readers and we encourage you to participate by using the ‘Comments’ section provided after each article or by contacting us directly by email. 

          As the past year progressed the number of visitors to Health Matters has exceeded some important milestones that a successful blog must attain.  We want to thank each of you for your loyal support and encourage you to continue visiting our site.  Here’s wishing you all a safe and healthy year ahead.

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Gout

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“So Painful It Hurts If You Even Look At It!”

That’s what my patients with gout have often told me when I am about to examine them.  A cloud of apprehension would envelop their face if my hand got anywhere near their swollen, painful great toe, the most common area affected by gout.  Many also told me they could not even tolerate the weight of a sheet over their toe!  While gout has been recognized as a medical condition for more than 4,000 years, it has become increasingly prevalent in the United States during the last two decades until now it affects 8.3 million Americans or 4% of the population.

The incidence of gout increases with age (it generally occurs after the age of 45) and men are affected more frequently than women.  Some studies suggest a connection between the increasing prevalence of gout and the increase in obesity and high blood pressure.  Some patients with gout have a genetic predisposition to this condition.  The significant disability caused by this painful form of arthritis makes it an important health issue.  Fortunately, with treatment, the symptoms of gout can be controlled and patients can lead a normal lifestyle.

What is Gout?

Gout is a type of arthritis characterized by inflammation in the joints and is caused by crystallization of uric acid within the joints.  Nearly 43.3 million Americans (21% of adults) have an increased amount of uric acid in the blood, defined as a level greater than 6.7 mg/dL.  When levels exceed this amount, uric acid can precipitate into tissues.  Small amounts of uric acid are normal in the blood, resulting from the metabolism or breakdown of purines.  Purines are a natural substance found in all of the cells of the body and provide part of the chemical structure of our genes.  The uric acid produced when purines are metabolized is normally excreted by the kidneys, unless the level exceeds the kidney’s ability to keep up.

While most patients with elevated uric acid levels do not experience clinical gout, an attack can be precipitated by eating foods high in purines, certain medications, trauma and surgery.  As you can see, there are a number of factors that can lead to the development of gout, including genetic factors, diet, high blood pressure, diabetes, obesity and kidney disease.

Clinical Manifestations 

          Gout occurs as acute intermittent attacks of joint pain, with redness, swelling and pain, often accompanied by fever and chills.  Attacks of gout often occur during the night and symptoms generally reach a crescendo during the first 12 hours from the time of onset.  The first attacks of gout usually affect only one joint and half of the initial episodes involve the joint of the great toe.

An attack usually lasts from 5 to 7 days and resolves spontaneously, but an attack can last up to 2 weeks.  There may be a long period of time between the first attacks of gout and subsequent episodes, but eventually they can become more frequent and begin to involve more than one joint and the upper extremities.  Some patients develop deposits of urate crystals in the soft tissue, known as tophi.

Diagnosis and Screening

Measuring uric acid levels as a screening mechanism is not recommended for asymptomatic individuals.  Since most patients with elevated uric acid levels do not develop gout, treatment of elevated levels is not indicated in the absence of clinical manifestations.  An elevated uric acid level is not diagnostic for gout and normal or low levels do not rule out gout.  All of this can make the diagnosis of gout somewhat difficult.

While your health care provider can make a presumptive diagnosis based on the overall clinical picture, a definitive diagnosis requires specific identification of the urate crystals which can be aspirated from the joint or tophi with a needle.  It is important to rule out an infectious cause for the inflammation, such as septic arthritis (infection within the joint requiring urgent treatment) and cellulitis (infection of the skin).

Treatment and Prevention

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in treating acute attacks of gout when used in maximum doses.  They should not be used in patients with kidney disease.  Corticosteroids, again in high doses, can also be effective and can be given orally, intravenously or injected directly into the affected joint.  Another drug called colchicine can be effective when only one joint is involved if is used within the first 24 hours of the onset of symptoms.  Beginning treatment soon after the onset of symptoms can reduce the severity of the attack.

Patients with mild hyperuricemia and symptomatic gout may be able to decrease their uric acid level by restricting dietary purines, losing weight and abstaining from alcohol.  Patients who experience frequent attacks of gout and have tophi or renal stones are candidates for therapy with a uric acid lowering agent such as allopurinol.  The goals of treatment are to ease the pain of acute attacks, reduce the number of attacks, prevent tophi and kidney stones and reduce the risk of long-term damage to affected joints.  Your health care provider can answer any questions you might have about gout and provide you with further information about this common condition.

Dietary Guidelines

The following dietary guidelines may help lower the uric acid level and are recommended for patients with symptomatic gout and elevated uric acid levels: 

High Purine Foods to Avoid:

-alcohol

-red meat

-seafood, especially shellfish

-food and drinks sweetened with high-fructose corn syrup

Low Purine Foods to Include in a Balanced Diet:

-low fat dairy products

-fresh vegetables and fruit

-nuts and grains

         

 

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Attention to Water Safety is Essential During the Summer.

Swimmer’s Ear

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Acute Otitis Externa

          With summer in full swing and people cooling off in swimming pools everywhere, this is a good time to review a common, though usually mild condition known as acute otitis externa or AOE.  If you parse out the words, what may seem like a complicated medical condition simply means acute inflammation (itis) of the external (externa) ear (ot is the Greek root word for ear).  But the more common term, swimmer’s ear, actually describes this condition just as well.

Attention to Water Safety is Essential During the Summer.
Attention to Water Safety is Essential During the Summer.

          It is estimated that each year swimmer’s ear (AOE) accounts for 2.4 million visits to a health care provider in the United States.  Children between the ages of 5 and 9 years have the highest incidence.  AOE is actually an inflammation of the outer ear canal manifested by redness, swelling, and itching and it is sometimes even accompanied by a discharge of pus.  One of the more prominent symptoms is pain, particularly with movement of the ear.

Bacteria Are the Culprits

          Two bacteria, Pseudomonas and Staphylococcus, are the most common causes of AOE.  Because high temperature and humidity are predisposing factors for this condition, the incidence is highest during the summer months and in areas of high humidity such as the Southeastern United States.

          Exposure of the external ear canal to water, particularly while swimming, causes the skin to become more vulnerable to trauma from such things as fingers or swabs.  The injured lining of the ear canal then gives bacteria an opening in which to begin an infection.  Swimmers who spend prolonged periods of time in the water and submerge their heads more frequently are at increased risk of AOE.  It is believed that prolonged contact with water can wash away the cerumen (ear wax) that provides a protective, water-repellent barrier.

Treatment

          Treatment consists of placing drops containing antimicrobials with or without corticosteroids in the ear canal for at least a week.  Treatment should continue for several days after symptoms resolve, which is usually by six days after treatment is begun.  Patients should not submerge their head in water for seven to ten days.

Prevention 

          The main strategies for preventing swimmer’s ear involve keeping water out of the ears as much as possible and maintaining a healthy barrier of skin lining the ear canal.  The Centers for Disease Control and Prevention (CDC) recommends the following steps to prevent and control swimmer’s ear:

-keep your ears as dry as possible

-dry ears thoroughly after swimming or showering, by using a towel and tilting the head to each side to allow water to drain

-avoid putting objects in the ear canal, like fingers and swabs, which can injure the ear canal

-don’t try to remove ear wax, which helps protect your ear from infection

-discuss with your personal physician whether you might benefit from use of ear plugs or preventive ear drops

-consult your physician if your ears are itchy, flaky, swollen or painful, or if you have drainage from your ears.

          Swimming is a great way to stay physically active and can provide hours of fun during the summer months and year round for many.  Just being aware of the causes of swimmer’s ear and taking a few precautions to prevent this painful infection can keep you from being sidelined while everyone else is having fun!

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Water Safety

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Overview 

          The beginning of summer is always a good time to review the importance of water safety.  Drowning deaths among children increase dramatically between the months of May and August.  While attention to water safety is a year round endeavor, warm weather increases our exposure to the dangers of water, whether it is in a swimming pool, play pool, lake, river or ocean, or simply the bath tub or a pail of water.  Knowing and following a few simple rules is essential for avoiding a preventable tragedy such as drowning.  Drowning is defined as death resulting from immersion injury within 24 hours of the event, while near-drowning is an immersion injury in which the person survives for at least 24 hours. 

The Grim Statistics 

          While children age 1 to 4 have the highest drowning rates, teens and adults should be aware of the dangers of water, as well.  Nearly 80% of people who die from drowning are male.  According to the Centers for Disease Control and Prevention (CDC), “every day, about ten people in the United States die from unintentional drowning.  Of these, two are children aged 14 or younger.  Drowning is the sixth leading cause of unintentional injury death for people of all ages, and the second leading cause of death for children ages 1 to 14 years.” 

The Danger Differs by Age Group 

INFANTS:  Infants most commonly drown in bathtubs or 5-gallon buckets used in the home.  Most deaths occur in the absence of adult supervision.  Bathtubs and buckets should always be emptied. 

PRESCHOOLERS:  The greatest dangers for preschoolers, age 18 to 30 months, are back yard pools and hot tubs.  Adult supervision and adequate fencing are essential.  Immediate performance of Cardio-pulmonary Resuscitation (CPR) can have a significant effect on the outcome of these accidents. 

SCHOOL AGE CHILDREN:  School age children are much more likely to drown in natural bodies of water than in backyard swimming pools.  Learning to swim, learning water safety rules and wearing appropriate personal flotation devices are the key to reducing risk in this age group. 

ADOLESCENTS:  Adolescents and young adults, age 15 to 24 years, have the second highest rates of drowning, after preschoolers.  These drownings most often take place in natural bodies of water with drowning among boys occurring more than six times as often as among girls.  Many of these accidents are associated with risk taking behavior and alcohol use.  Since diving injuries account for a number of injures in this age group, teens and young adults should be taught to jump feet first the first time they enter the water.  Personal flotation devices should be used for water activities such as boating, sailing, water-skiing or using jet skis. 

Simple Steps to Prevent Drowing 

           Summer should be a time of fun for children, teens and adults.  Swimming and other water sports are a healthy activity and provide a good form of physical activity which is important for maintaining overall health and fitness.  Some of the important steps to prevent drowning and other water related accidents can be summarized as follows: 

-maintain proper supervision by a responsible adult around water

-never swim alone, but always with a buddy

-learn to swim

-learn cardiopulmonary resuscitation (CPR)

-avoid alcohol before or during water related activities or while supervising children

-install proper fencing if you have a swimming pool

-use personal flotation devices when indicated 

Here’s hoping you have a fun, healthy and safe summer!

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