History

Fact Explanation
Diarrhoea Rotavirus is a RNA virus, that causes most common form of acute diarrhoea in children less than 5 years of age. [4] After exposure to infected material, they develop diarrhoea following 1-3 months of incubation period. [5] Diarrhea is defined as the passage of three or more stools that are looser in consistency than normal within a 24-hour period. [3] Rotavirus usually causes watery diarrhoea. [5]
Fever [7] Rotaviruses attach to cell surface receptors on mature enterocytes at the tips of villi in the small intestine and causes invasion. [5] Absorptive capacity is reduced, secretory mechanisms are stimulated, and ultimately Villous ischaemia occurs due to damaged intestinal microcirculation. [6] Releasing pyrogens during the inflammation might cause the fever.
Vomiting, nausea [7] This is a much more common symptom. [5]
Lethargy, malaise Though this is a mild disease, [6] patients might be having some constitutional symptoms.
Age Age below 2 years is significantly associated with rotavirus infection. [4]
Social history: male gender, maternal smoking, maternal age < 20 years Studies have shown that these factors are associated with increased risk of rotavirus diarrhoea. [2]
References
  1. GRANDY GIUSEPPE, MEDINA MARCOS, SORIA RICHARD, TERáN CARLOS G, ARAYA MAGDALENA. Probiotics in the treatment of acute rotavirus diarrhoea. A randomized, double-blind, controlled trial using two different probiotic preparations in Bolivian children. Array [online] 2010 December [viewed 07 July 2014] Available from: doi:10.1186/1471-2334-10-253
  2. NAKAWESI JANE S, WOBUDEYA ERIC, NDEEZI GRACE, MWOROZI EDISON A, TUMWINE JAMES K. Prevalence and factors associated with rotavirus infection among children admitted with acute diarrhea in Uganda. Array [online] 2010 December [viewed 07 July 2014] Available from: doi:10.1186/1471-2431-10-69
  3. MADHI SHABIR A., CUNLIFFE NIGEL A., STEELE DUNCAN, WITTE DESIRéE, KIRSTEN MARI, LOUW CHERYL, NGWIRA BAGREY, VICTOR JOHN C., GILLARD PAUL H., CHEUVART BRIGITTE B., HAN HTAY H., NEUZIL KATHLEEN M.. Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants. N Engl J Med [online] 2010 January, 362(4):289-298 [viewed 07 July 2014] Available from: doi:10.1056/NEJMoa0904797
  4. MEDICI MC, MARTINELLI M, ARCANGELETTI MC, PINARDI F, DE CONTO F, DODI I, VIRDIS R, ABELLI LA, ALOISI A, ZERBINI L, VALCAVI P, CALDERARO A, BERNASCONI S, IZZI GC, DETTORI G, CHEZZI C. Epidemiological aspects of human rotavirus infection in children hospitalized with acute gastroenteritis in an area of northern Italy. Acta Biomed [online] 2004 Aug, 75(2):100-6 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15481698
  5. CUKOR G, BLACKLOW NR. Human viral gastroenteritis. Microbiol Rev [online] 1984 Jun, 48(2):157-179 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC373217
  6. THAPAR NIKHIL, SANDERSON IAN R. Diarrhoea in children: an interface between developing and developed countries. The Lancet [online] 2004 February, 363(9409):641-653 [viewed 08 July 2014] Available from: doi:10.1016/S0140-6736(04)15599-2
  7. NGUYEN TV, LE VAN P, LE HUY C, WEINTRAUB A. Diarrhea Caused by Rotavirus in Children Less than 5 Years of Age in Hanoi, Vietnam J Clin Microbiol [online] 2004 Dec, 42(12):5745-5750 [viewed 14 September 2014] Available from: doi:10.1128/JCM.42.12.5745-5750.2004

Examination

Fact Explanation
Febrile This may be a low grade fever. [2]
Sunken eyes, dry skin, dry mucous membrane, reduced skin turger Rotavirus diarrhoea is one of the commonest cause of severe dehydration. [,2]
Low blood pressure May be due to dehydration. [1]
References
  1. NAKAWESI JANE S, WOBUDEYA ERIC, NDEEZI GRACE, MWOROZI EDISON A, TUMWINE JAMES K. Prevalence and factors associated with rotavirus infection among children admitted with acute diarrhea in Uganda. Array [online] 2010 December [viewed 07 July 2014] Available from: doi:10.1186/1471-2431-10-69
  2. NGUYEN TV, LE VAN P, LE HUY C, WEINTRAUB A. Diarrhea Caused by Rotavirus in Children Less than 5 Years of Age in Hanoi, Vietnam J Clin Microbiol [online] 2004 Dec, 42(12):5745-5750 [viewed 14 September 2014] Available from: doi:10.1128/JCM.42.12.5745-5750.2004

Differential Diagnoses

Fact Explanation
Watery diarrhoea This can be due to vibrio cholerae and Toxigenic E. coli etc. There can be occasional passage of blood with stools. [1]
Shigella and enterohemorrhagic E. coli (EHEC) These infection are different from rotaviral diarrhoea as shigella can have bloody diarrhea as the predominant symptom. Shigella dysenteriae is the one causes dysentery(bloody diarrhoea). [1]
Inflammatory bowel disease Crohns disease and ulcerative colitis belong to this group. There is a dysregulated mucosal immune response to the normal commensal flora in a genetically susceptible host. [2]They will present with systemic features such as fever, weight loss, malaise etc associated per rectal bleeding. They usually have a long term history of diarrhoea.
Amebiasis Entamoeba histolytica is the causative factor for the parasitic disease"amebiasis". Clinical features would be abdominal pain, watery, bloody, or mucoid diarrhea due to colitis. Stool microscopy will show red blood cells, macrophages and polymorphonuclear cells. Amoebic liver abscess is an extraintestinal manifestation of amoebiasis. [4]
Giardiasis This is a waterborne infection. Diagnosis is made by detection of Giardia lamblia cysts and trophozoites on examination of the stool sample. [3]
References
  1. FIELD MICHAEL. Intestinal ion transport and the pathophysiology of diarrhea. J. Clin. Invest. [online] 2003 April, 111(7):931-943 [viewed 07 July 2014] Available from: doi:10.1172/JCI18326
  2. BLUMBERG RS. Inflammation in the Intestinal Tract: Pathogenesis and Treatment Dig Dis [online] 2009 Nov, 27(4):455-464 [viewed 08 July 2014] Available from: doi:10.1159/000235851
  3. JANOFF EN, CRAFT JC, PICKERING LK, NOVOTNY T, BLASER MJ, KNISLEY CV, RELLER LB. Diagnosis of Giardia lamblia infections by detection of parasite-specific antigens. J Clin Microbiol [online] 1989 Mar, 27(3):431-435 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC267335
  4. FOTEDAR R, STARK D, BEEBE N, MARRIOTT D, ELLIS J, HARKNESS J. Laboratory Diagnostic Techniques for Entamoeba Species Clin Microbiol Rev [online] 2007 Jul, 20(3):511-532 [viewed 08 July 2014] Available from: doi:10.1128/CMR.00004-07

Investigations - for Diagnosis

Fact Explanation
Enzyme-linked immunosorbent assay (ELISA) Stool samples can be used to identify the virus. [1]
Polymerase-chain-reaction (PCR) If the stool sample is positive for rotavirus, then it is assessed by PCR and next hybridization assay. [1]
Stool microscopy Can be used to detect the organisms. [2,3]
Stool full report Can be used to exclude other conditions like amoebic cysts, ova as these also can present with watery diarrhoea. [3]
References
  1. MADHI SHABIR A., CUNLIFFE NIGEL A., STEELE DUNCAN, WITTE DESIRéE, KIRSTEN MARI, LOUW CHERYL, NGWIRA BAGREY, VICTOR JOHN C., GILLARD PAUL H., CHEUVART BRIGITTE B., HAN HTAY H., NEUZIL KATHLEEN M.. Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants. N Engl J Med [online] 2010 January, 362(4):289-298 [viewed 07 July 2014] Available from: doi:10.1056/NEJMoa0904797
  2. CUKOR G, BLACKLOW NR. Human viral gastroenteritis. Microbiol Rev [online] 1984 Jun, 48(2):157-179 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC373217
  3. ITURRIZA-GóMARA M, AUCHTERLONIE IA, ZAW W, MOLYNEAUX P, DESSELBERGER U, GRAY J. Rotavirus Gastroenteritis and Central Nervous System (CNS) Infection: Characterization of the VP7 and VP4 Genes of Rotavirus Strains Isolated from Paired Fecal and Cerebrospinal Fluid Samples from a Child with CNS Disease J Clin Microbiol [online] 2002 Dec, 40(12):4797-4799 [viewed 14 September 2014] Available from: doi:10.1128/JCM.40.12.4797-4799.2002

Investigations - Fitness for Management

Fact Explanation
Full blood count As this is a viral infection that can present with increased lymphocytes in the blood (lymphocytosis). As the patient is presenting with the fever, it is important to exclude other infections presenting with the fever. eg:- increased white cell count in bacterial infections and reduced platelets count in dengu [2] and other viral infections.
Serum electrolytes Electrolyte loss can leads to hypokalaemia, hytponatraemia and hypochloraemia. [1]
References
  1. FIELD MICHAEL. Intestinal ion transport and the pathophysiology of diarrhea. J. Clin. Invest. [online] 2003 April, 111(7):931-943 [viewed 07 July 2014] Available from: doi:10.1172/JCI18326
  2. PHUPONG VORAPONG. . BMC Pregnancy Childbirth [online] 2001 December [viewed 14 September 2014] Available from: doi:10.1186/1471-2393-1-7

Investigations - Followup

Fact Explanation
Serum electrolytes Electrolyte imbalances are improving as infection settles. [2]
IgA antibody After the rotaviral vaccine, blood samples are taken to assess the serum concentrations of antirotavirus IgA antibody. [1]
References
  1. MADHI SHABIR A., CUNLIFFE NIGEL A., STEELE DUNCAN, WITTE DESIRéE, KIRSTEN MARI, LOUW CHERYL, NGWIRA BAGREY, VICTOR JOHN C., GILLARD PAUL H., CHEUVART BRIGITTE B., HAN HTAY H., NEUZIL KATHLEEN M.. Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants. N Engl J Med [online] 2010 January, 362(4):289-298 [viewed 07 July 2014] Available from: doi:10.1056/NEJMoa0904797
  2. FIELD MICHAEL. Intestinal ion transport and the pathophysiology of diarrhea. J. Clin. Invest. [online] 2003 April, 111(7):931-943 [viewed 07 July 2014] Available from: doi:10.1172/JCI18326

Investigations - Screening/Staging

Fact Explanation
Serum electrolytes To see any electrolyte imbalances during diarrhoea. [1]
References
  1. FIELD MICHAEL. Intestinal ion transport and the pathophysiology of diarrhea. J. Clin. Invest. [online] 2003 April, 111(7):931-943 [viewed 07 July 2014] Available from: doi:10.1172/JCI18326

Management - General Measures

Fact Explanation
Controlling pain, fever and vomiting Analgesics and antipyretics can be used to control the any associated pain and fever. [5] Antiemetics can be used for vomiting.
Prevention Proper hand hygiene is crucial in preventing the diarrhoeal infections. Arrangements to improve the hygiene, sanitation, and providing access to clean water are essential steps in prevention. [4]
Probiotics Probiotics are important in shortening the duration of diarrhoea. S boulardii, L.acidophilus, L. rhamnosus, B. longum are some of the species used as probiotics. [1]
Vaccine There is a rotavirus vaccine for infants, which causes significant reduction in severe rotavirus diarrhoea. [3] It is a live attenuated oral vaccine. Intussusception is a known to be a side effect of vaccination. [2]
Zinc therapy Malnourished or zinc deficient children are benefited by zinc supplementation as it reduces the incidence, frequency, severity of diarrhoeal illnesses. [4]
References
  1. GRANDY GIUSEPPE, MEDINA MARCOS, SORIA RICHARD, TERáN CARLOS G, ARAYA MAGDALENA. Probiotics in the treatment of acute rotavirus diarrhoea. A randomized, double-blind, controlled trial using two different probiotic preparations in Bolivian children. Array [online] 2010 December [viewed 07 July 2014] Available from: doi:10.1186/1471-2334-10-253
  2. DE WIT M. A. S., KOOPMANS M. P. G., VAN DER BLIJ J. F., VAN DUYNHOVEN Y. T. H. P.. Hospital Admissions for Rotavirus Infection in the Netherlands. Clinical Infectious Diseases [online] 2000 September, 31(3):698-704 [viewed 07 July 2014] Available from: doi:10.1086/314025
  3. MADHI SHABIR A., CUNLIFFE NIGEL A., STEELE DUNCAN, WITTE DESIRéE, KIRSTEN MARI, LOUW CHERYL, NGWIRA BAGREY, VICTOR JOHN C., GILLARD PAUL H., CHEUVART BRIGITTE B., HAN HTAY H., NEUZIL KATHLEEN M.. Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants. N Engl J Med [online] 2010 January, 362(4):289-298 [viewed 07 July 2014] Available from: doi:10.1056/NEJMoa0904797
  4. THAPAR NIKHIL, SANDERSON IAN R. Diarrhoea in children: an interface between developing and developed countries. The Lancet [online] 2004 February, 363(9409):641-653 [viewed 08 July 2014] Available from: doi:10.1016/S0140-6736(04)15599-2
  5. NGUYEN TV, LE VAN P, LE HUY C, WEINTRAUB A. Diarrhea Caused by Rotavirus in Children Less than 5 Years of Age in Hanoi, Vietnam J Clin Microbiol [online] 2004 Dec, 42(12):5745-5750 [viewed 14 September 2014] Available from: doi:10.1128/JCM.42.12.5745-5750.2004

Management - Specific Treatments

Fact Explanation
Rehydration There is loss of fluid and electrolytes during the diarrhoea leads to dehydration, hyponatraemia, hypokalaemia, and metabolic acidosis. Prevention and management of dehydration is important to prevent deaths due to diarrhoea. [1] Currently recommended oral rehydration solution has a total osmolarity of 311 mmol/l with sodium (75 mmol/L), potassium, chloride, citrate and glucose anhydrous in adequate amounts. As The glucose-sodium co-transporter is preserved in diarrhoeal diseases, the ORS can provide the deficient fluids and electrolytes in diarrhoea.
Management of dehydration Management of mild to moderate dehydration, requires rehydration with 50-100ml/kg over 3-4 hours. Usually around 60 ml of ORS per each stool is required for the replacement. Severe cases need intravenous fluid replacement with 0.9% normal saline/ringer's lactate. [1]
Diet and nutrition Breast feeding should be continued during the episode. [2] No restriction for other food items. In developing countries, where recurrent Diarrhoea is common in undernourished children. It is like a vicious cycle: undernutrition causes diarrhoea and diarrhea then again leads to undernutrition. [3]
Antibiotic treatment Antimicrobial therapy is not recommended for rotavirus infection. [4]
References
  1. MUNOS MK, WALKER CL, BLACK RE. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. Int J Epidemiol [online] 2010 Apr:i75-87 [viewed 07 July 2014] Available from: doi:10.1093/ije/dyq025
  2. LENTERS LINDSEY M, DAS JAI K, BHUTTA ZULFIQAR A. Systematic review of strategies to increase use of oral rehydration solution at the household level. Array [online] 2013 December [viewed 07 July 2014] Available from: doi:10.1186/1471-2458-13-S3-S28
  3. THAPAR NIKHIL, SANDERSON IAN R. Diarrhoea in children: an interface between developing and developed countries. The Lancet [online] 2004 February, 363(9409):641-653 [viewed 08 July 2014] Available from: doi:10.1016/S0140-6736(04)15599-2
  4. RODRIGUEZ-ROISIN R, FéLEZ MA, CHUNG KF, BARBERà JA, WAGNER PD, COBOS A, BARNES PJ, ROCA J. Platelet-activating factor causes ventilation-perfusion mismatch in humans. J Clin Invest [online] 1994 Jan, 93(1):188-194 [viewed 14 September 2014] Available from: doi:10.1172/JCI116944