INFECTIONS AND FEVERS

Most common infections are viral - e.g. colds, 'flu, sore throats, gastroenteritis. Even ear and chest infections are often viral in healthy people. All the common childhood infections - measles, mumps, rubella & chickenpox - are also viral with the exception of Scarlatina which is streptococcal. There are three important points to make about viral infections - very few can be directly treated by drugs, most healthy people can throw off most viral infections using their own body's immunity and many viral infections can be successfully prevented by immunisation (especially the more serious ones like polio, measles and hepatitis A&B). To find out more about the difference between viruses, bacteria and fungi go to BUGS. Treatment of fever is covered in temperature.

• Measles. Full-blown measles is, thanks to the MMR injection, now very rare. It takes two or three days to evolve into the complete picture of any itchy pinkish-red  blotchy rash (which FADES on pressure - the "glass test") starting with respiratory symptoms initially - cough and upper respiratory congestion - and conjunctival inflammation and runny eyes. Often the patient finds bright light very uncomfortable (photophobia). The diagnostic sign consists of fine white spots inside the cheeks. This is a notifiable (to environmental health) disease but nearly all suspected measles cases now turn out to be something else.  All notified cases are followed up by a saliva test a couple of weeks later to confirm or refute the diagnosis so that an accurate assessment of the disease incidence can be made.

• Mumps. Causes inflammation of the parotid salivary gland in front of the ear. This is quite painful and often starts on one side then migrates to the other. Adults may get involvement of other glandular tissue such as the testicles, ovaries or pancreas. Like measles this is now so rare with MMR immunisation that a parotid swelling is almost certainly not mumps  these days. A saliva test is done to confirm the diagnosis or otherwise a couple of weeks or so after infection. This is for statistical reasons and has no use in the treatment of the infection.

• Rubella (German Measles) Unrelated to measles this is usually a much milder illness when it occurs in children with a fine pink rash and some enlarged glands behind the ears. Adults often feel worse with 'flu-like symptoms as well including joint pains. The real significance is the risk to pregnant mothers - especially in the first few weeks of pregnancy when the pregnancy may not even be diagnosed. Consequently infected patients, though often fairly well in themselves, need to stay out of circulation for about four days - or until the rash fades. As with measles and mumps this is a notifiable disease and the diagnosis is checked for epidemiological reasons with a saliva test after a couple of weeks. Now with good take-up of MMR it is fortunately quite rare. Women intending to become pregnant may have a blood test to check on immunity which can be boosted by an injection if found deficient. This MUST be done BEFORE pregnancy and pregnancy avoided for three months or so afterwards. Any pregnant woman who thinks she may have been exposed to rubella and is not sure that she is immune should seek immediate advice from her GP or Community Midwife.

• Chickenpox. Usually a mild though uncomfortable illness with a blistering rash on mainly the trunk it occasionally has more serious consequences. Patients whose immunity is impaired (due to cancer therapies, steroids, AIDS/HIV, inherited immune deficiences) or who have severe eczema may get much more ill than normally is the case and unlike most viral illnesses there is effective drug treatment for the varicella zoster virus which causes both chickenpox and shingles. Urgent medical advice is required in these specific instances though for most chickenpox cases this is not so and all that is needed by the majority of patients is symptomatic treatment with paracetamol and perhaps calamine lotion. The rash continues to come out in crops for several days and may extend into the orifices causing much discomfort and distress. We do not, however, normally treat uncomplicated cases with anti-viral drugs. Because of the risk to vulnerable patients as detailed above and because it remains infective for a considerable time cases should remain out of general circulation for ten to fourteen days, even if they feel quite well in themselves.

• Shingles. The same virus as chickenpox which is reactivated after a dormant period of up to sixty or seventy years though occasionally it occurs in children and young people and there may be no recollection of a previous episode of chickenpox. The rash is similar to chickenpox though confined to the territory, in virtually every case, of one nerve root. Typically the rash does not cross the midline to the other side of the body and often there is a strikingly straight border. The risks to vulnerable groups are similar to chickenpox. Additionally, we get concerned when the rash gets close to the eye and in the elderly pain for months after the rash can be a problem (post-herpetic neuralgia). In all such cases anti-viral drugs may be required but these need to be started early - ideally within a day or so of the onset of the rash. Sometimes there may be pain for several days before the rash appears and this may be difficult to diagnose before any spots can be seen.

• Glandular fever (infectious mononucleosis) Caused by the Epstein-Barr virus. Symptoms vary from very slight to a debilitating illness with a bad sore throat, enlarged lymph glands (hence the name), general malaise and even jaundice due to a mild hepatitis. There is no treatment and sometimes the patient may be under the weather for weeks. It is common in, but not exclusive to, adolescents and it is thought that it may be transmitted in the saliva in kissing (the kissing disease). Often it is picked up when a case of "tonsillitis" doesn't get better with antibiotics. There is a specific blood test which confirms the diagnosis but which takes a week or so to go positive. This may also be used to monitor progress. The patient should avoid strenuous activity, especially in the early stages, and contact sports and "rough-housing" should be avoided in the first week or two as the spleen may be enlarged and hence liable to be damaged. Often there is a mild hepatitis even if jaundice is not apparent so it is wise advice to avoid alcohol for at least three months - longer if possible.

• Influenza A frequently misused term for a bad cold. The 'flu proper is an unpleasant illness causing severe malaise, aching joints and limbs, headache, temperature and some upper respiratory symptoms such as sore throat, cough etc. It is caused by an influenza virus and may occur in epidemics (occasionally massive global epidemics are called pandemics) or as a sporadic case. Epidemics usually occur around the turn of the year. People are often made to feel very ill and there can be diagnostic confusion with more serious illnesses such as meningitis People with respiratory or heart problems, diabetes or other conditions affecting immunity may become more severely ill with 'flu itself and can develop, for example, a serious chest infection. If you have a serious chronic illness and you think you have the 'flu or if you think you have a chest infection (with a cough productive of COLOURED sputum, temperature and perhaps noises coming from your chest on breathing) then you should see us to get checked out.    There is also a good immunisation to protect you from the current active strains of 'flu if you fall into a group that is considered vulnerable by virtue of health status or communal living in a nusing or residential home (each year we get a statement of current policy on 'flu vaccine eligibility so if you're in doubt because you've not had it before, then check with us by asking the receptionist to find out for you). Current policy is to immunise all those aged 65 and over.

• Hepatitis The main strains of these are A, B and C

  • Hepatitis A. An illness of mild to moderate severity. It's a viral infection causing an inflamed liver, 'flu-like symptoms and jaundice (yellow skin). It is passed by the faecal/oral route (i.e. poor hygiene) similar to food poisoning. Certain parts of the world are high risk (e.g. Cairo) but nowhere is immune. There is an immunisation but avoidance of uncooked/undercooked food and tap water condiderably reduces the risk - remember : ice cubes are usually just frozen tap water and freezing has no effect on the virus and very little effect on food poisoning bacteria. Fortunately full recovery is the norm for this the mildest of the three types of hepatitis.
  • Hepatitis B. This can also be fairly mild but it can also be severe causing liver failure and occasionally death. There is a long-term carrier state and some patients go on to a chronic hepatitis, cirrhosis and even liver cancer. Like hepatitis C and HIV/AIDS it is a blood-borne disease transmitted by contact with an infected person's blood and some bodily fluids - i.e. by contact with blood itself, contaminated needles or surgical instruments and by unsafe sexual practices. It is much more easily transmitted by these routes than HIV and is at least as common world-wide and probably commoner in most parts of the world. There is an immunisation but it takes a minimum of three injections before it provides adequate protection and uptake has to be confirmed by blood test as further injections may be required and a small minority never develop useful immunity.
  • Hepatitis C. This is often asymptomatic and picked up on random screening tests done for other reasons such as the screening of donated blood by the transfusion service. Often there are persistent low-grade abnormalities of the liver blood tests along with a positive immunological test for the hepatitis C virus. There is a treatment with a type of interferon which some patients benefit from. It is given by injection over a period of time, causes 'flu-like symptoms and there are a significant number of patients who respond insufficiently or relapse. Like hepatis B there is a significant worry about long-term effects such as cirrhosis/liver cancer and more than 10% suffer significant problems
• Pneumonia This is an infection of the lung tissue itself causing cough, difficulty breathing and fever and can be life threatening. There are a variety of causes: specific bacteria such as the pneumococcus, complications following the 'flu, general anaesthesia or poor general health, aspiration after vomiting or partial drowning and often as a terminal event in the elderly or chronic sick. Milder cases can be dealt with by antibiotics in the community. More severe cases need admission to hospital. To be distinguished from bronchitis where a productive cough is present but where the patient is often not that ill in themselves. It goes without saying, I think, that pneumonia always requires medical attention and assessment and can only be diagnosed after a full examination of the chest by a doctor plus, in many cases, a chest x-ray.
• Tonsillitis, ear infection, sinusitis - all forms of upper respiratory tract infection. In normally fit adults and older children there is often no need for antibiotics though they are frequently given. Where symptoms persist for several days, where there is underlying illness, in the elderly or in young children it is wise to get a medical opinion. These symptoms, in addition to a fever and feeling unwell, consist of a bad sore throat/difficulty swallowing, earache/partial deafness or headache mainly over the front of the head. The exact symptom pattern is dependant on where the infection settles and on its severity. Paracetamol or ibuprofen help the fever and pain and steam helps to relieve congested noses etc..
• Urine infection A frequent cause of fever and feeling generally unwell or "fluey". Pain on passing water, below the tummy-button or in the loin area is often but not always present. A simple urine screening test which can be performed in the surgery may indicate the presence of an infection but a lab test (an "MSU") is needed to pinpoint the exact cause. Where the patient is unwell in themselves or in a lot of pain we may commence antibiotics whilst awaiting lab. results.

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