RSV Respiratory Infections Often Come with Pneumococcal Bacterial Infections

RSV2Respiratory syncytial virus (RSV) is the leading cause of bronchiolitis in infants and was the cause of over 700,000 hospitalizations of young children from 1992 to 2009 or over 40,000 hospitalizations a year in the US. Each winter this disease causes many parents to come into the office with their infant breathing hard and fast, with a sticky mucous-like cough and what seems to be a wheeze (noisy exhale). When the illness gets bad they can no longer breast feed or take their formula and they eventually may need oxygen support which is when they typically end up in the hospital.

The study “Pneumococcal Disease in Infants: A Time Series Analysis of US Hospitalization Data,” (which you can read here… ) showed that among children under one year old, 20% of the pneumococcal pneumonia cases were associated with RSV, and for children 1-2 years old, 10% of the pneumococcal pneumonia cases were associated with RSV infection.

Pneumococcal pneumonia is both more dangerous than RSV alone, and treatable, so identifying it is important when a child under age 2 seems to have RSV bronchiolitis and possible pneumonia. Physicians tend to feel confident that they have identified the source of the problem when they have proven for example that a sick infant has RSV.  We tend to attribute symptoms to one infection.  This study should put doctors on alert that when you have an especially ill looking infant with bronchiolitis, consider the possibility of pneumococcal infection as well.

Working in my urgent care recently, on one weekend I had three very ill RSV positive infants with pneumonia clinically.  I obtained a complete blood count (CBC) and in all three of these cases the white blood cell count (WBC) was over 25,000 with mostly neutrophils (a pattern we see with bacterial disease). Some physicians are aware that WBC counts that high are almost always caused by strep pneumococcus.  All three of these infants were treated with antibiotics and hospitalization was prevented.  Note that RSV is viral and antibiotics have no place in the treatment of viral illness.

This article is important since it provides significant evidence to support obtaining a CBC in the very ill bronchiolitis infant and when the WBC is sky high (over 20,000) consider treating for pneumococcal pneumonia and bacteremia.

Dr. Paul



Influenza Update USA, Oregon- Christmas 2014

FluIf you live in the middle of the USA, Texas, or Puerto Rico you are seeing plenty of influenza.  Most of the USA and Oregon, where I live, is just beginning to see the first cases of this flu season that will likely peak in February or March this year. 82% of the Oregon samples were H3 type (23 cases confirmed). The good news is that this looks to be a mild season.  For those in my practice who would like protection, we do have the vaccine in the mercury-free single dose shots. It is definitely not too late to come and get that shot. In Oregon 17-35% of residents have taken the flu shots of early December.  This matches what I see in my practice.

If you have underlying medical conditions like asthma, lung or heart disease or are in any other way medically fragile or sickly, then getting the flu is much more dangerous for you and you should get the flu shot.  If you will be around someone who is potentially at higher risk, it makes sense that you get the protection.  Make sure you get the single dose mercury-free shot.

This year the flu vaccine is not as effective against the H3 strain that is circulating, but still gives a little protection.  This year the flu mist (nasal spray vaccine) is not working well for those under age 8 years, but still gives a little protection.

You can read more about the current state of Influenza in the USA by clicking here…



Dr. Paul



Limb Weakness and Severe Respiratory Symptoms Reported With the D68 Enterovirus Infection

enterovirusThose who lived in the first half of the 20th century (1900-1950) have clear memories of the polio epidemic.  We have not had a new case of polio acquired in the USA since 1979. The CDC HEALTH ADVISORY September 30th (you can read here… ) reports on nine children with focal limb weakness and MRI abnormalities in the grey mater of their spinal cords.

All children had fevers and cold and cough symptoms in the 2 weeks before they developed limb weakness (weak arms or legs). Of the eight nasal viral cultures, six were positive for enterovirus/rhinovirus and of these six, so far 4 were Enterovirus D68 (EV-D68) with the other two pending.

The US is currently experiencing an outbreak of EV-D68, with 500 cases the past two months in 42 States. Read more here…


States with Lab-confirmed EV‑D68 Infections
States with Enterovirus






From mid-August to October 1, 2014, a total of 500 people in 42 states and the District of Columbia have been confirmed to have respiratory illness caused by EV-D68. Learn more about states with confirmed cases here…

Enterovirus D68 was recently associated with increased respiratory symptoms and has been causing fever, runny nose, cough, and body aches, but also triggering severe asthma with difficulty breathing.  While we have had no confirmed cases in Oregon, we had a patient in my office with known asthma hospitalized yesterday (October 1) who fit this pattern.

Infection spreads from saliva, nasal secretions, sputum, and droplets from sneezing or cough. Enterovirus infections (there are over 100 different kinds of enteroviruses) are usually in the summer and fall.  The younger you are, the less likely you are to have immunity against enteroviruses.  Those with asthma are particularly at risk of more severe symptoms.  If your child seems to be working hard to breathe, struggling for air, or coughing way more than usual, please have them evaluated.

As of October 1st, 2014, while 4 people who have died were found to be positive for EV-D68, it is unclear whether or not it was the actual cause of death.

Treatment is supportive. Nasal/throat swabs can be sent to the CDC for EV-D58 testing in those children sick enough to need hospitalization, or those showing limb paralysis symptoms.


Prevention is the key.  WHAT CAN YOU DO TO AVOID INFECTION?

  1.  Good hand washing, especially after using bathrooms, changing diapers, touching contaminated surfaces.
  2.  Avoid touching your nose, mouth, or eyes with unwashed hands.
  3.  Don’t share food that has touched another person’s hands or lips, or share drinks or eating utensils.
  4.  Disinfect toys, door knobs and frequently touched surfaces.


Dr. Paul




Study Validates “bare-below-the-elbows” Policy Reduces Doctors Spreading Infections (Hawaii shirts finally validated!)

hawaiian-shirt-300x246Those who know me, are surprised when I am not in a Hawaiian shirt.  In medical school I got in trouble for not having a tie on and in fact was going to be failed and kicked out of medical school if I did not put on a tie during my medicine rotation. 

Numerous studies have shown that white coats, uniforms, and ties are often colonized with harmful pathogens (you can read more about that here… ). 

So to my medical school professor- 🙂

My basal metabolism is one temperature- HOT.  I could not be a surgeon as I would sweat in the operating room and drip on the field of surgery, not to mention being a bit claustrophobic and unable to wear masks. My freshman year in college I wore Hawaiian shirts at Kalamazoo College, running between buildings for months with snow on the ground. 

Of course hand washing is the single most important way to prevent the spread of infections. If your physician is not doing that, please remind them. 


Dr. Paul


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