case STUDIES

Author: Lauren S. Schlesselman, PharmD

CASEONE:

EC, a healthy 22-month-old toddler, is brought to the pediatrician's office with a 1-to 2-week history of loose stools. His mother reports that EC has loose stools 6 to 7 times per day. This contrasts with the 1 to 2 stools that he normally has. The consistency of EC's stools is so loose that his diapers are unable to contain them.

On physical examination, the pediatrician finds EC to be a playful, happy toddler in no acute distress. His vital signs are:

EC has gained 2 lb since his last physical and remains in the 75th percentile for his age. Except for perineal erythema due to frequent stooling, the pediatrician does not report any abnormal findings during the physical examination. The physician, suspecting that EC has giardiasis, decides to send a stool sample for evaluation for ova and parasites. The results of the laboratory testing confirm the pediatrician's suspicions by reporting the presence of numerous Giardia lamblia cysts. The pediatrician explains the results to EC's mother and writes a prescription for EC to start furazolidone 8 mg/kg/day divided into 4 daily doses for 10 days.

EC's mother is very concerned about the diagnosis, particularly when the pediatrician explains that giardiasis is often referred to as a "swimming pool" disease. The disease is often transmitted via swimming pool water due to contamination with feces from an infected swimmer. EC's mother frequently takes her children to the lake to swim. Although her other children do not have symptoms, she asks the pediatrician if she should treat all of the children.

Should all of her children be treated even if they are asymptomatic?


CASE TWO: In a rural town, a mother comes to the walk-in clinic located in the local pharmacy. She has brought 7 children with her; 6 are her own, ranging in age from 4 months to 6 years. The other child, aged 3, is her niece who has been staying with them while her siblings are recovering from "some sort of sickness."

The mother explains that her niece has developed symptoms similar to those the siblings had. She is concerned that her children will also develop symptoms. She describes a 3-day history of fever, a hacking cough, clear rhinorrhea, nasal congestion, decreased appetite, and decreased activity. Although the fever has resolved, a rash has appeared on the child's face and neck. Now the rash is progressing downward.

On physical examination, the practitioner notices a generalized, erythematous, maculopapular rash. The girl's oral mucosa is red and granular with white spots on it. She also has conjunctivitis with watery eyes and photophobia.

The practitioner is concerned that the symptoms are consistent with measles. He contacts the health department and confirms that the girl's siblings were all reported as being serology-positive for measles.

When the practitioner informs her of the suspected diagnosis, the mother admits that her own children were never immunized. She wants to know what can be done to protect her children from developing measles. Are there any measures that can be used to prevent measles in exposed children?

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.


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CASE ONE: Treatment is not necessary for children who are asymptomatic. Colonization with Giardia does not appear to harm the children. Treatment does not reduce the infection rate. The Centers for Disease Control and Prevention recommends treatment of asymptomatic children who are not having diarrhea if they have nausea, fatigue, weight loss, or a poor appetite. If several family members develop symptoms (or several children within a day care center), screening and treating of asymptomatic children may be appropriate.

CASE TWO: If given within 72 hours of exposure, measles vaccination may provide some protection for children over the age of 1 year. Postexposure vaccination is preferable to immune globulin in most cases. Immune globulin should be used in exposed individuals who are pregnant or immunocompromised. Exposed children under the age of 1 year should receive immune globulin.