Search for tag: "infections"

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an academic dermatologist at Texas Tech University Health Sciences Center. And joining me is . . .

Dr. Johnson: Hi, everybody. This is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about molluscum. Luke, as a pediatric dermatologist, I know you see this condition all the time. So what are molluscum?

Dr. Johnson: I see it so frequently. I usually see multiple cases every day. That's how common it is. But before I became a dermatologist, I didn't even know it existed. So it's kind of shocking that it's so common and yet most people don't seem to know about it, assuming most people are like me and didn't know about it. It is caused by a virus, and it causes little bumps on the skin, little smooth, almost wart-like bumps. The most common ages are ages 2 to 10. And the important thing to know is that it's not dangerous, and it eventually goes away on its own.

Dr. Tarbox: I love that not dangerous part. I like the full name of the condition as well, because it tells people a little bit about potentially how they might acquire it. So we know that it's caused by a virus. What virus causes this?

Dr. Johnson: It's a type of virus called poxvirus. And the virus is just in the skin. Some people sometimes worry that the virus is like in their child, or in their blood, or something, and it's coming out in the skin. But that's not the case. The molluscum virus affects only the skin. And because it's technically a poxvirus, it can leave little tiny scars. Unfortunately, sometimes when the spots go away, there are sort of like pockmark scars. But they're very small and they seem to improve over time a lot more than some other scars. So that's usually not a big deal, even if they show up on the face or some other area where they might be more obvious.

Dr. Tarbox: That's something I've noticed as well, that immediately after they resolve in small children or when it happens in young adults, there are these little slit-like scars. But as the child grows, usually those fade quite significantly. And I've not been able to successfully find old, like, molluscum scars in an adult.

Dr. Johnson: No, I've never seen that either. So if you have a child with molluscum, I wouldn't worry about the scar, though there might be a little scar there for maybe a year or two.

Dr. Tarbox: Now, how do kids get molluscum? Like I think that the easiest way to explain this is to give people the full name of the virus, which is molluscum contagiosum because it is quite contagious. And so like other contagious things, we get it from somebody else, like somebody with molluscum. What's the best way to get it, Luke? If you are going out to get molluscum, how would you do that?

Dr. Johnson: Press your skin against somebody else's molluscum-covered skin.

Dr. Tarbox: Preferably while it's wet.

Dr. Johnson: Preferably while it's wet. While it's wet, it's spreads even easier. So I think this is why it's most common between ages 2 and 10, because kids have to be old enough to kind of be playing with other kids. And by the time you're 10, usually your immune system has already been exposed to it and your immune, or your immune system just takes care of it really quickly. So especially skin-to-skin contacts, usually through play, especially when it's wet, like in a pool or sharing a bath, sharing a towel, stuff like that. Some people refer to these as water warts I think for that reason.

Dr. Tarbox: Yeah. I think that that's one of the simplest ways to pass it. So the summertime is coming up or is already here. If you've got a little one that has these little molluscum, what can you do to kind of like help prevent them to spread?

Dr. Johnson: Unfortunately, not very much. So if you have a couple little kids, and they generally take a bath together, and one of them has molluscum, but the other one doesn't, I suppose you could think about not bathing them together anymore. Though, honestly, both children have probably already been exposed. So you might look at the supposedly molluscum free one very closely, and maybe they just have one or two bumps that you didn't notice before. Plus, I have two kids, if they have a bath together, especially when they were a little bit littler than they are now, it's just nice for the parents to have 30 minutes when the kids are happy and playing in the water for you to do something. And there's only so much we could do to prevent the spread of molluscum anyway. So I'm not sure that it's worth it to bathe them separately and go through all of that. But that's potentially something you can do.

They are quite contagious, so kids can spread them in their own skin by potentially scratching them or something, but they aren't very itchy usually. And they often will spread regardless of a parent's best efforts to tell the kid to stop rubbing it, stop scratching it, keep them covered up. They just spread. I'm sorry, it is what it is. But I am a silver lining kind of guy. So I like to focus on the good news is that they're not dangerous, and they go away on their own.

Dr. Tarbox: So when you were talking about, like, looking at the other kid to see if maybe they have some molluscum, how could they tell if something was molluscum? What would be the characteristic pattern that you would look for?

Dr. Johnson: Well, you can certainly look this up on the internet for some pictures, but they're smooth, dome-shaped, skin-colored or pale bumps. They sometimes have a little dimple in the middle. We call that being umbilicated, like your umbilicus, which is your belly button. So it almost looks like they have a little belly button. And sometimes they don't have that, but they do have an even paler center than the rest of them, like a little pale core. That's actually where the infectious virus is.

Dr. Tarbox: Yeah. When we're looking at these in the clinic, sometimes we'll use a special magnifying device that we call a dermatoscope. And that actually will let us see that little white core that has all of the infectious stuff in the middle. I had one teenage patient that was very industriously using a comedone expresser to kind of pop the little molluscum out. And she was quite enjoying the process of that. Sometimes that can be fun. We had a little possible budding Dr. Pimple Popper there. It was very cute. So sometimes that's a similar thing to a treatment we do in the office. So if we do nothing, what happens?

Dr. Johnson: Well, like I said, they go away. But they can take a long, long time to go away, a frustratingly long time. I'm sorry. Focus on the good news, not dangerous and they will go away. The average length of time they're supposed to stick around is about six months. The longest I have seen is five years. At least the patient's parents told me they had been there for five years. And like I said, it seems that the older you are, the faster your body clears them.

And sometimes when your body starts to clear them, they just sort of start disappearing, which is great. But sometimes when the immune system becomes active against them and finally wakes up, the molluscum can kind of appear different. So sometimes they get a rash around them, almost kind of looks like eczema. They get this itchy pink rash around them. And sometimes the molluscum themselves get inflamed. They can become swollen, big, painful. They can look infected. A lot of times patients, parents, or even other doctors think they're infected. But really, it's just the immune system finally becoming active against this molluscum. Sometimes we call it the beginning of the end sign, and it usually means the molluscum is going to go away in the next two to three months. But I do have some patients where the immune system seems to kind of beat up on the molluscum for a while and then take a little break, and beat up on them some more and then take a break. So if your child has starting to get these inflamed or rashy molluscum, and it's been going on for a month, then you're probably in good shape and they're going to go away. But if that's been happening for like five months, then I'm less optimistic.

Dr. Tarbox: Yeah, I agree. And sometimes that immune response can kind of stutter a little bit. I know you know this about me, Luke, but some of our listeners might not know that I'm a mega dork. And so I've actually written a little book chapter about infectious diseases, one of them being molluscum. And did you know that they have something in common, Luke, with either "Star Trek" or "Harry Potter"?

Dr. Johnson: Please, tell me.

Dr. Tarbox: So molluscum contagiosum can actually hide themselves from the immune system. They make a protein that actually makes it difficult for the immune system to see them, which is the reason why, at first, they tend to be flesh colored, not inflamed at all. So it's either an invisibility cloak or a cloaking device, whichever one you prefer in terms of the metaphor. But when that starts to be able to be seen through by the immune system, that's when we start to get that immune reaction, which is usually a harbinger of success with treatment. So I know they can go away on their own and they're generally harmless, but let's say we have a patient that really can't stand these things, wants them to be gone. How do we take care of these things?

Dr. Johnson: Well, remember, they're going to go away, and they're not dangerous. So because of that reason, I don't like to use treatments that could be uncomfortable, or painful, or could even scar. You know, it's kind of hard for me to justify that medically for something that's going to go away on its own. But reasons to potentially treat. If the child is motivated, for example, if they're motivated to get a shot that might make them go away, then probably we should go ahead and treat them. Usually, that's in the older kids, like the 8, 9, and 10-year-olds. Usually, the 3 and 4-year-olds just don't care that they're there. If the molluscum are spreading all over the face, then that's potentially a reason to do it, especially if it's causing trouble at school. And speaking of schools, occasionally I've had preschools or daycares, who have acted kind of strange about molluscum and have said that your child can't come back until these are gone, which seems absurd. I'm happy to like write a letter saying they should not keep your kid out of school. But sometimes we just have to treat them for that reason.

And then sometimes, I get it. I know my parents . . . This is what I assume they're thinking to themselves when they look at me, and I tell them all of this, "I hear where you're coming from, Dr. Johnson, not dangerous, and they're going to go away on their own. But they've been here for 18 months, and I hate them. I hate them so much. I think about them. I look at my child and I see them, and it just is driving me crazy. And I'm at the end of my rope. Can't we do something?" And if you're at that point, then I also think that they're probably worth doing something about.

Dr. Tarbox: Yeah, I agree with you. You know, sometimes we can do more harm than good if we're too aggressive in treating something that's harmless. So we want to balance those risks. But if it is causing significant distress, there are some things that we can do. So what is your first thing you reach for, Luke?

Dr. Johnson: Well, the first thing I reach for if I'm in clinic is actually a shot that I mentioned. It's called Candida antigen. And it's supposed to inspire your immune system to attack them. So one of the nice things about it is we just inject into the skin under one spot, and it's supposed to inspire your immune system to attack them all. I have seen it work miracles. I've also seen it do nothing. So if you want a dermatologist or somebody like that to do it, usually we plan on three shots each a month apart to see if it works.

But there's stuff you can do at home as well. So there's a little bit of evidence that zinc can help the body fight viral infections. And you can get zinc in over-the-counter pastes. They are, in fact, in diaper pastes, and they're kind of messy. But other than that, they're totally safe. So if you want to do something that might help and is totally safe, you can use one of these diaper pastes. The ones that seem to have the most zinc in them include Desitin Max Strength, Boudreaux's Butt Paste Maximum Strength, and Baby Butz with a Z. We're not sponsored or anything by any of these companies, by the way. Those are just some that might work.

Dr. Tarbox: I love it. I think that those gentle, easy things that people can do at home can be very, very helpful. For some patients we'll also kind of try to cause a little irritation. So we mentioned the fact that the virus can hide itself from the immune system. And our immune system is really how we get rid of this virus. So helping our immune system find the virus is sometimes a useful strategy in treatment. So we can irritate them sometimes with topical retinoids, which can either be over-the-counter products, such as Differin, which contains the active ingredient adapalene, which is a version, kind of a cousin of Retin-A. It's a vitamin A derivative. And tretinoin, which can be prescription.

There are other home remedies or other over-the-counter products that are designed to do something similar. There's something called MolluscumRX. I have no connection to this product. It's a sort of homeopathic treatment that uses a combination of essential oils to sort of irritate the immune system. I think that that's an approach that can work in some patients. There's something called thuja oil that can be used. It's a derivative of sort of a pine plant that has an essential oil that can sometimes cause a little bit of mild irritation that might bring the immune system to the fore. So that's also something that can be useful.

But I think that some of the most concerning things that arise around the issue of molluscum is sometimes people mistake the infection for something much more nefarious. So kids, like you pointed out, tend to pick at the molluscum, even if they're not itchy. And, you know, kids tend to kind of scratch other parts of their body as well. And so, occasionally, you can get spread of the molluscum to the swimsuit area. And occasionally, people can get concerned about a possible STD in a child who has molluscum in that area. But most of the time, that is autoinoculation, meaning the child had molluscum somewhere else, scratched it, and touched the part of their body that is covered by the bathing suit. And then the molluscum is there, not by any kind of abuse but just by auto transfer.

Dr. Johnson: Yeah. They're actually pretty common in the diaper area, especially of like little kids, age 2 to 3 or so on. So don't get worried about that unless, of course, your gut is telling you that something suspicious could be going on. In adults, though, in the genital area, they are considered a sexually transmitted disease. So we take that seriously. In terms of adults getting it, adults are generally immune. I think that almost all of us just see the virus when we're kids and become immune. Though, occasionally, I've had a parent of a child with molluscum, and I've found one or two spots in their forearm or something like that.

Dr. Tarbox: Yeah. I think that, you know, you don't see it so often in adults. They tend to get rid of it faster. It tends to be less persistent. But it can be quite distressing, especially if it occurs in an area that people can see. And I always try to also approach the conversation of the transfer of the virus gently because sometimes adults will also pick it up from like gym equipment or something, you know, sporty, and non-adult in nature. So, of course, being cautious not to cast any aspersions or anything like that. So what other, like, things can look like molluscum?

Dr. Johnson: Well, you probably want to go to a professional if you feel like you might have molluscum, but it's acting funny, especially if there's a problem with your immune system. So there are people out there who have diseases or have to be on medicines that turned their immune system down. And even if they had been immune to molluscum before, their immune system got turned down. Now molluscum might come back, might get worse. And then there's other rare infections that can look like molluscum in people whose immune systems aren't working right. So go see somebody if you think that describes you.

Also, before we finish talking about molluscum, you mentioned earlier about how do you prevent them from spreading. And I said there's not really a great to do it. But if your child has molluscum, I don't think that's a reason to like keep him out of the pool or anything, you know, because you want to be like a good neighbor and prevent it from spreading to other kids. I don't think molluscum should prevent him from playing in the pool. But you might want to like put on some waterproof Band-Aids or have them wear a rash guard or some other kind of swim garment in order to prevent the spread as much as you can.

Dr. Tarbox: Well, and as dermatologists, we love the rash guard because that also provides great sun protection, and you always want to think about that when you're doing outdoor, water-based activities.

Dr. Johnson: Yep. My daughter has a swimsuit that goes neck to wrists to ankle. She's totally covered up. I don't think she has molluscum. But if she did, it wouldn't be spreading to anybody.

Dr. Tarbox: Exactly.

Dr. Johnson: Well, thanks so much for joining us today, listeners. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. If you feel like you're a dermatology nerd, like we are, you might be interested in our other podcast.

Dr. Tarbox: Our other podcast is called "Dermasphere." It is aimed at dermatology professionals and people who are dermatologically curious. It's a little bit longer and more technical. It's about an hour. And we cover current research in the topics of dermatology and dermatologic disease.

Dr. Johnson: That is correct. So come check us out there if you like. Otherwise, we will see you here next time.

Interviewer: Sepsis. What is it, how do you get it, and what should you do about it? That's next on The Scope.

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician. I wanted to learn a little bit about sepsis today. What exactly is sepsis? Let's start there.

Dr. Madsen: Well, sepsis is, you know, a word you may have heard, but the best way to think about sepsis is it's just an infection that started somewhere, either in the lungs or the urine or on the skin, like a urinary infection, a skin infection, that then works its way through the entire body. So it's basically just a full-blown form of stuff that otherwise might not seem like that big a deal, that you could just take some antibiotics for.

Interviewer: All right, so a localized infection is not sepsis?

Dr. Madsen: No.

Interviewer: It's when that infection somehow gets into the bloodstream. How common is that that that's going to happen?

Dr. Madsen: It's not super common. It's more common in people who are older who have immune system problems. That's where we often see cases. But I mean, I've absolutely seen people who have come in with urinary tract infections, young, healthy females, who it works it way up to their kidneys. From there, you start to see the effects throughout their body.

And really, the effects we're looking for to call it sepsis are high temperature, so they're coming with a fever, they're breathing rapidly, their heart rate is going fast. We check blood work on them. Their white blood cell count, which is a sign of infection more throughout the body, is elevated. And then, sometimes in severe sepsis, their blood pressure even drops, just because that severe infection can cause the blood vessels to dilate. So that blood pressure's going to drop, and that's where it gets really serious.

Interviewer: So it could happen to anybody, even if you're healthy, more likely if you have a compromised immune system. Something to avoid, nonetheless. Are there ways to avoid getting sepsis?

Dr. Madsen: So really, the key to avoiding sepsis is to catch infections early. If you look at your arm, it looks like you have a skin infection. Let's say you have an area of a lot of redness, warmth. You touch it, you just say, "Wow, this is really hot here." You need to get on some antibiotics, because those are the things that can then progress to sepsis as that infection spreads. You're having urinary tract symptoms.

The times I see these cases of sepsis are people who might let it go for a couple of days, and then it works its way up. They start having back pain, fevers. That's when it becomes urosepsis, so starting from the urine and then that infection working its way through the body. Or pneumonia, the other common thing, people who are coughing a lot, high fevers. Things get much worse there. So if you can catch these things early, get on antibiotics, you can generally avoid that really severe form of the infection that we call sepsis.

Interviewer: All right, and if sepsis does kick in, what's the treatment for that?

Dr. Madsen: So sepsis, it requires hospitalization. So in these patients, and we've done a lot of studies in the ER, how do we best treat these patients, but the key is getting on top of it early. And what that means is getting IVs in, giving fluids. Just because people can be very dehydrated, they can have a lot of fluid loss from this. And then getting antibiotics early. I'm going to start antibiotics very early on these patients who come in who are septic and admit them to the hospital, often admitted for several days on IV antibiotics while trying to figure out exactly what caused the sepsis and making sure it's treated appropriately.

Interviewer: And why the long-term hospitalization on that? Why not just give antibiotics and let them treat it at home?

Dr. Madsen: Well, one of the challenges, they often need additional IV fluids, and they often need that IV form of antibiotics. Some of the IV forms are much stronger than what we could give at home, and so that's why they're in the hospital, monitoring them. This can be a life-threatening condition. I mean, some studies that were done on sepsis several years ago even showed that, you know, in these cases, they were finding 30% of patients with sepsis were dying. Maybe it's not that high now. I'm sure it's not now that we've improved our care, but this is a big deal. So these patients are often admitted and for several days.

Interviewer: So to me, it sounds like, if you experience some sort of an infection, especially some of the ones that you mentioned, that you should get on top of that and treat that so the sepsis doesn't ever become a problem. But then, if the symptoms start happening, you absolutely need to go to the hospital.

Dr. Madsen: Exactly. Once you get fevers, chills, you know, just things getting much worse, the back pain, like an infection in the kidney, just a cough that is just not getting better and you're bringing stuff up, lots of phlegm, yeah, get to the ER. This may be something more serious that requires some IV antibiotics.

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Interviewer: All right, it's time to play the game ER or Not, where you get to play along and decide whether something that happened is worth going to the emergency room or not.

Dr. Troy Madsen is an emergency room physician at University of Utah Health. All right, here is today's ER or Not. You've got your ear pierced. Now you believe that there might be an infection in the ear. ER or not?

Dr. Madsen: So when you think of an ear piercing, you might think, "Okay, this is a pretty minor thing." Maybe you got your ear pierced, maybe there's just a little bit of redness around it. And again, that would be a pretty minor thing and something you don't need to go to the ER for if it's just some local irritation or maybe just a small infection. You could probably go to an urgent care or go see your doctor. But there's so much else going on around the ear that can really cause problems.

So the ear is made of cartilage. If you get an infection that's spreading up beyond just the site of the piercing, where the full ear appears red and swollen or just even the lower half of it, then I would be a lot more concerned about an infection in the cartilage itself, and that would definitely be a reason to go to the ER.

Interviewer: So a cartilage infection is a lot worse than infections elsewhere. Why is that?

Dr. Madsen: It's just tougher to treat, you know? You figure cartilage doesn't have all of the blood going into it. You don't have all the vessels running into it so if you start antibiotics, it has a tougher time getting into that. So if you have an infection that's getting down into the cartilage of the ear, we may need to think about IV antibiotics, you know, something where we're admitting you to the hospital for that. And then behind the ear as well, the bones back there are notorious for getting infected and that can be a very serious thing as well.

So if someone comes into the ER and they've got ear pain and ear swelling, and then I push on the bones behind the ear, kind of at the base of the skull there, and they're really tender there, that can be a very serious thing too. And that, typically, requires IV antibiotics, sometimes even surgery.

Interviewer: So beyond the dangers of an infection, which infections aren't good, is there a danger to the actual ear itself if this goes untreated?

Dr. Madsen: Absolutely. Yes, I mean, you could have damage to the cartilage, you can have a breakdown of that cartilage, something that could cause long term issues, possibly deformity there.

Interviewer: So they're hearing loss?

Dr. Madsen: Absolutely. If you get enough swelling in there and enough long term issues, you could have some sort of, at least, hearing impairment or hearing issues. So, you know, it's kind of the thing again you hear about it, maybe an infection from an ear piercing sounds pretty minor but there's just so much going on around the ear. If that infection spreads, if it's deep or if it's into the bone absolutely come to the ER. Probably IV antibiotics, hospital admission for that.

Interviewer: So be sure you're going to a reputable place and don't let your friends do it, I guess is the lesson here, right?

Dr. Madsen: Yes. To me, too many memories as a kid of seeing kids in the boy's bathroom with a needle, stick it into the ear trying to piece their ear. You don't want to do that. This is not a home procedure.

updated: June 19, 2020
originally published: April 28, 2017

Dr. Miller: Artificial joints and infection, we're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Jeremy Gililland. He is a Professor of Orthopedic Surgery here at the University of Utah in the Department of Orthopedics. For patients and people who have prosthetic joints or artificial joints, are they at higher risk of having an infection in that joint?

Dr. Gililland: Well, the joint itself we put in is a metal and plastic joint. It inherently doesn't have its own immune system like our own joints do. So if you get an infection, even an innocuous infection in the blood stream that would have normally been cleared, there is a chance that could get to the joint and take over and so you are at more risk of that joint becoming infected.

Dr. Miller: So how does one become infected? I mean, is that due to a cut or some other site in the skin that could be infected or is it some other way that you are infected? How does that happen?

Dr. Gililland: The answer is, probably most of the time we don't know how it happens. It comes about as an infection that we probably wouldn't have picked up otherwise or have been aware of otherwise. Sometimes we are aware, they had a bad urinary tract infection or they do get an infection in the skin and that then gets to the joint, but most of the time we don't know and these come on seemingly out of the blue.

Dr. Miller: How often does it happen? I mean, it's not common, right?

Dr. Gililland: It's not common. We would say that in most big registries, infection in any given practice should be about 1% to 2%. There is difference in infection that happens right around the time of surgery which would be a surgical site infection which can come from either the wound itself.

Dr. Miller: The wound itself, healing, the incision.

Dr. Gililland: Exactly and that's different than infection that ensues say two or three years down the road in an otherwise well-functioning joint.

Dr. Miller: So you see infection more commonly after surgery or two or three years down the road?

Dr. Gililland: Generally what we see here is our infection rate here at the university is very low. It's less than 1% of our own infections and in cases that happen here in terms of patients getting surgical site infections, but we definitely see infections coming in from outside or infections in patients that have had well-functioning joints and that's probably a bigger problem in terms of dealing with those long-term.

Dr. Miller: So dealing with an infection in a prosthetic joint is a different kind of beast than having an infection in a joint . . . in a normal joint.

Dr. Gililland: Correct. Dealing with an infection in a prosthetic joint is rather difficult because now you have a piece of metal in there that's infected and we are starting to learn more about infections and the way that they form and bacteria is just a single bacteria creating infection. They create a big environment of what we call a biofilm that's almost . . .

Dr. Miller: Sticky.

Dr. Gililland: Right.

Dr. Miller: They stick to the plastic and the metal and . . .

Dr. Gililland: Exactly. They almost create their own colony and their own surface that sticks to the metal and it's almost impossible to get rid of with just antibiotics.

Dr. Miller: So I think most people would believe that you might just take an antibiotic for a few weeks and then the infection would go away, but that's not really true in this situation.

Dr. Gililland: Yes, it's very, very unlikely that that's going to be successful and often we get patients that have come in and have been on antibiotics for a long period of time and that's been rather unsuccessful for them and it makes our job somewhat harder because now these bacteria can be somewhat resistant to some of these antibiotics.

Dr. Miller: Well, let's talk about the patient who might have an infection. What signs would they look for, what symptoms would they have that would alert them to the fact that they might have an infection in that new prosthetic joint?

Dr. Gililland: Yeah, the biggest thing is pain. Most of these patients are patients that were functioning well, doing well with their arthroplasty, their joint replacement, and then they started to develop pain down the road. And whenever that happens, the patients need to go and be seen and be evaluated to make sure the parts aren't loose and there is no fracture, and most importantly, they don't have an infection.

Dr. Miller: But there could be other reasons for pain aside from the infection.

Dr. Gililland: Absolutely. Pain in and of itself does not mean infection, but it's certainly something that we ought to be looking for. Any painful joint that comes in that was otherwise well functioning always gets an infection workup in my clinic.

Dr. Miller: Would there be other things going along with the pain? So would the joint be swollen or red or will the patient have fever or chills? What kinds of things are you typically seeing in these infections that occur two to three years out?

Dr. Gililland: Yes. So certainly there you can have swelling about the joint, redness. You can get drainage from the wound or start to develop draining sinus tracts or sites of drainage.

Dr. Miller: That would be bad.

Dr. Gililland: Yeah, that's obviously, obvious signs of infection. Patients can have fevers or systemic symptoms where they start to feel sick, nauseated, lightheaded, those kinds of things. That could be a sign that they are becoming septic from this. Those are the things that are . . .

Dr. Miller: What is septic?

Dr. Gililland: Sepsis is when the body system actually becomes infected, it gets into the bloodstream and you start to have multi-organ involvement from the infection.

Dr. Miller: Fever, chills, sweats, dizziness . . .

Dr. Gililland: Blood pressure issues . . .

Dr. Miller: . . . nausea. That's actually a very severe infection and of course should be treated quickly.

Dr. Gililland: Absolutely.

Dr. Miller: So what do you do if antibiotics alone are not going to fix this problem? You as an orthopedic surgeon intervene and what are the things that you do to cure that infection?

Dr. Gililland: Generally, this chronic situation where the patient has been well functioning but now has an infection, the likelihood is it's usually an infection that's probably been there for longer than we think. We treat those infections, it's a rather invasive process. Meaning, we need to go in, we need to take out all the metal because again the metal has the slime layer that's created by the bacteria that we can't just get rid of. We think we can scrub it, but reality is our data which show that we're not very good at that. So we go in, we take all the parts out.

Dr. Miller: So this is a real big deal and somebody who has had a hip replacement, now their prosthetic is removed and they're going to need a new one at some point.

Dr. Gililland: Absolutely. In our minds most of the time it involves the two-stage process. Meaning, we take out all the parts, we put in a temporary joint replacement usually made out of cement with antibiotics impregnated in that cement that gives antibiotics to the bone, to the tissue. And after a period of IV antibiotics and a period of time off the antibiotics, if everything looks like it's been eradicated successfully, then we go back and try to rebuild the joint.

Dr. Miller: You talk about a period of time, how long is that actually?

Dr. Gililland: Usually three months minimum.

Dr. Miller: The other thing that comes to mind is now that the prosthetic joint is out, how does the patient get around? What do they do?

Dr. Gililland: That all depends on what we put back in. Usually we can put back in something that functions. Meaning, they have structured limb and they can still use the limb, but most of the time we don't let them put much weight on the limb, so they're using a walker or crutches to get around and trying to keep the weight off of it because again we are putting in a temporary part that's really not designed to be structurally sound for a long period of time.

Dr. Miller: So they're also on long-term antibiotics during this time, is that correct? Once you take the hardware out.

Dr. Gililland: Absolutely. They're usually on a period of six weeks of antibiotics IV and then after that if everything looks like it's getting better and their labs are normalizing, then we'll stop that, we'll give them what we call an antibiotic holiday to see if their labs remain low and make sure the infection does not recur once they're off of their antibiotics.

Dr. Miller: Once you complete this treatment and get to the point where you're going to put a new joint in, how successful are you in terms of really knocking out that infection, making sure it doesn't come back?

Dr. Gililland: That's a tough question to answer. I think everybody thinks we're better at than we really are. If you look at the literature, it's probably somewhere in the realm of about 75% success with that type of a two-stage process. But I think it really has to do with the patient and the patient's medical comorbidities and it has to do with the bug and how receptive that bug is to the antibiotics, what kind of bug it is, how virulent it is and then how many times they have attempts at prior surgeries.

We sometimes have patients that come in that have had four or five other attempts at surgery and at that period of time, he got an infection that's been really dwelling in there for many upwards of several years and it's very, very difficult for us in those cases to get rid of it. And I would say sometimes during the realm of about 50-50.

Dr. Miller: Obviously, this is a very big deal for somebody who has had a prosthetic joint put in. What tips would you give to patients or what advice would you give patients to prevent infection if that's possible?

Dr. Gililland: Absolutely. I think that's the ultimate crux to this is how do we prevent the problem from happening in the beginning. There are several things that we know put patients at risk for infection. Uncontrolled diabetes is a big risk. Being a smoker is a big risk. Morbid obesity with body mass index is probably somewhere above 40 puts you at risk. Other risk factors for infection such as rheumatoid arthritis or being on immunosuppressive drugs can put you at risk.

All these things need to be evaluated by your surgeon preoperatively before you have the initial joint replacement and that's something that we do very vigilantly here at the university. We make sure that we try to mitigate any risk factors that we can preoperatively to avoid infection in the beginning.

Dr. Miller: What about little cuts and nicks on the skin? Does that bother you?

Dr. Gililland: No, I don't think. I mean, if you have a little cut and nick on the skin, as long as it's healing well and it doesn't show any evidence of infection, I don't think you have to be extra vigilant about everything in life. I mean, I think most people have a well-functioning joint and get along very, very well and we're talking about a small percentage of people here. But I think it just takes a reasonable approach.

Dr. Miller: So bottom line is if you have a hip or a knee that's been replaced, and you have pain, you should have that checked out by your orthopedic surgeon or another competent provider that can actually look to make sure that you don't have an infection as a cause of that pain. And if you have infection, that needs to be treated aggressively.

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Interviewer: What should you do if you have a case of diarrhea? We're going to find out next on The Scope.

Announcer: This is From the Frontlines, with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. Let's talk about diarrhea and what should somebody do if they start having diarrhea? Should they be taking some medication? Should they be going to see their doctor? When should they start worrying?

Dr. Madsen: So diarrhea is obviously not the most pleasant topic. It's something probably all of us have dealt with at some point or another. But it's one of those things where you kind of have to give it time. And we do occasionally have people who come to the ER who have had diarrhea for say 12 hours or so. And they're very concerned. And they don't look particularly dehydrated, they've been able to drink plenty of fluids and stay hydrated. They don't have other medical issues that would make them more likely to get really dehydrated. So those are the kind of situations where you know, you really want to give it some time to see what happens.

Because most cases of diarrhea, assuming it's from some sort of a bug or maybe something you ate, are going to get better within 24 hours. Maybe they'll last two days, maybe up to three days, but even if someone comes to the ER and they said, "I've been having diarrhea for two or three days." And I look at them and it's not like their lips look really dry and their eyes look sunken or they look like they're just really dehydrated. And they're not the kind of person who has lots of medical issues that would make them more likely to get dehydrated. I say, well, not a lot of testing we really need to do here. We don't really need to test for really unusual infections. You're probably going to get better within a day and usually it does.

So if you're someone who has diarrhea I'd say, give it a couple of days. Keep drinking fluids. You can try drinking electrolyte drinks. Those might help and make a difference. You're not losing lots of electrolytes, which can be an issue. But if it's gone on for longer than that.

If you're getting beyond three days and maybe into four or five days and maybe you've been camping recently. Or you've been swimming in mountain streams or lakes or drinking from mountain streams. Or you have a new pet. Or you have a pet turtle you found out while you were traveling and you pulled it out of a stream. These unusual things that would set you up for something more serious like giardia or salmonella. Things where we start to think about unusual infections. Those would be cases to come to the ER or see your doctor and get tested for that.

Interviewer: So generally, up until about two days, if somebody came into the ER you wouldn't run many tests if they looked healthy and they weren't at high risk of something else, you just have them wait and see?

Dr. Madsen: Most likely. I mean the reality of the ER there is the dynamics of the ER where the fact that someone comes in the door they often just get testing done. But it's typically not really necessary.

Interviewer: So if it was a family member you would say just wait it out for another day or so?

Dr. Madsen: I would. If a family member called me and said I've had diarrhea for a day or two I'd say wait it out. I would ask them has it been bloody diarrhea? That raises concern for me. But most of these cases people are just having kind of normal diarrhea. Just frequent bowel movements. Watery, they're not describing blood in their bowel movements. If you're seeing those sorts of things, that's going to change things a bit. But, typical diarrhea. Give it a couple of days.

Interviewer: Would you recommend taking any sort of antidiarrheal?

Dr. Madsen: If we're worried about an infection like salmonella. So those unusual cases where let's say you've had recent foreign travel or you have had recent exposure to mountain streams and you're drinking from mountain streams or swimming in lakes. There we're hesitant to say use something like Imodium. Just because people that have those infections can then become chronic carriers of the disease or it can make things worse. But in the average case of diarrhea where those are not a concern, I think Imodium is perfectly fine. I don't think there's a problem at all. If it can help you get through the day, get through work, whatever you have to do. No issues with that.

Again we're talking here about the average person who doesn't have a lot of medical issues. Times where you would be more concerned about diarrhea. Even after a day or two would be . . . If you do have some medical problems that make you more prone to dehydration. Maybe you take a water pill. Something for heart failure or for kidney issues that takes water off. And then you're losing fluids because of diarrhea. Maybe you then start to feel light headed. Or you're dizzy. These would all be things where I would say where I would say yeah, you need to come to the ER. You may need some IV fluids. We may need to rehydrate you.

Also, very young children. If they are really just not taking fluids well. When they cry, they're not making tears. Their eyes look sunken. You look at their mouth, their lips look dry. Again, reasons to go to the ER even after maybe even 12 to 24 hours of diarrhea.

Interviewer: Sounds like in the common cases it's dehydration you're most worried about?

Dr. Madsen: Exactly, dehydration and then along with that electrolyte abnormalities where you can lose electrolytes with the diarrhea.

Interviewer: All right, so watch out for those things. Think about, have I done anything strange or unusual recently that might be the cause of this that could be a little bit more insidious. Otherwise just wait it out.

Dr. Madsen: Exactly, give it some time. It'll run its course. You'll probably get better within a day or two.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 30, 2018
originally published: September 6, 2016

Interviewer: You think you or maybe your kids have pinkeye. How will you know for sure and what should you do about it? We'll talk about that next on The Scope.

Announcer: This is From the Front Lines with emergency room Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. Pinkeye. Let's talk about how you would diagnose a case of pinkeye and then what you would do about it because I hear it could be kind of difficult to diagnose like a school nurse, for example, might not be able to tell the difference from allergies or not. Is that the case?

Dr. Madsen: That is the case. And that's always what I'm thinking in my mind. So the most common thing we have is someone comes in and they say, "My eye hurts" or "My eyes hurt". I look at their eyes, they're red. So a couple of questions I ask and I say, "First of all, did this start in both eyes or did it start in one eye and spread to the other?"

If it starts in one eye, that's more likely what we would call pinkeye. And pinkeye is a bacterial infection often. Sometimes it's a viral infection but it's really tough to tease out which are bacterial and which are viral. Of course the ones we worry more about are the bacterial infections because we're going to treat those with antibiotic drops, but you figure it's not going to necessarily start in both eyes at the same time. It kind of start somewhere. It's going to start in one eye and then maybe you're rubbing that eye and then it spreads over to the other eye. So typically with pinkeye, that's the case.

Interviewer: Okay, so one eye hurts before the other generally.

Dr. Madsen: Exactly.

Interviewer: Red like bloodshot red, what's that red look like?

Dr. Madsen: So the red . . . Yes, that's tough to distinguish from allergies.

Interviewer: There's nothing really unique about it, huh?

Dr. Madsen: Not particularly. It can look a lot like allergies where just if you've ever had like allergies, just seasonal allergies, your eyes are bloodshot, they hurt, they itch, pinkeye looks very similar. With pinkeye though, we often see more discharge or more drainage from the eye. This kind of stuff that's not so much, just your eyes watering, which you have with allergies, but stuff that's kind of a little more whitish in color that looks more like you would imagine an infection looks.

So someone who says they wake up and my eyes are like matted shut. Again, allergies, we can sometimes see that but it's usually more with pinkeye. They have to pry their eye open or their kids' eye or they use like a washcloth and hold it on there to kind of loosen that up and pry it open. That's pretty typically with pinkeye and that helps me out to make that diagnosis.

Interviewer: All right. So then what does treatment look like? You said if it's a bacterial cause, then you would use antibiotic drops. It's hard to tell though, so you just . . .

Dr. Madsen: It is.

Interviewer: You just use antibiotic drops across the board or . . .?

Dr. Madsen: Typically yes, and you don't want to over-treat with antibiotics, but in practical terms, if I were to try and get a culture of the eye, send that to the lab, it takes couple days to get the result. It's not really that useful. So even though it might be viral, it's often bacterial so we treat with antibiotic drops. It means using drops several times a day or often for a week just make sure this clears up. Most people are going to have improvement in their symptoms after two or three days.

Interviewer: What if it's viral though and you're using the drops, they're not doing anything, will it just get better on it's own or . . .?

Dr. Madsen: It will.

Interviewer: Really?

Dr. Madsen: It will. Yes, with the viral it will just get better on its own and the antibiotic drops probably aren't going to do a whole lot for it but, again, it's hard to say because maybe after two or three days, you're feeling better and it could be that the virus got better on its own or maybe the drops treated the bacteria. But it's not the sort of thing, again, where a culture would be that helpful because it's going to take two or three days to get the results back. If it's bacterial, it could get significantly worse and really progressing, cause some issues wherein you can get infections around the eye or extending behind the eye as well.

Interviewer: And untreated, could it cause long term problems if you didn't go into anything about it or would it eventually just clear up regardless?

Dr. Madsen: It could clear up but the concern with the bacterial infections would be something that progresses, again, to where it spreads around the eye.

Interviewer: Infects the rest of, yes, other parts of your eye.

Dr. Madsen: Exactly. And so that's why even though in my mind I say, "Okay, this could be a viral infection," I'm also saying, "I want to treat this as likely a bacterial infection because the possibilities with the bacterial infection could be pretty significant." And I don't necessarily want to tell this person, "Wait two or three days and then come back when you have a significant infection around your eye that might require even something like IV antibiotics or hospital admission," if it got to that point and got that serious.

Interviewer: And don't need to go to an emergency room for this sort of thing. Urgent Care or a primary care provider probably would be able to take care of it.

Dr. Madsen: Absolutely.

Interviewer: And you could . . . even if you have to wait a day?

Dr. Madsen: Yes. Even if you had to wait a day, you're probably okay. I think the challenge for most parents is if their kid gets pinkeye, they're not going to let the kid come to school because it is highly contagious. You've got to make sure you're washing your hands, your kid's washing their hands. Kids get this at school, they pass it to other kids. So a parent's probably not going to want to wait a day to get in to see their primary care doctor. They'll go to an Urgent Care. If you have to come to the ER, you come to the ER. Either way, I'm guessing most parents want to get that treated and get their kid back to school and get them out of the house as soon as they can.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: October 2, 2018
originally published: August 19, 2016

Dr. Jones: If the womb is such a safe place, how does the Zika virus get in? This is Dr. Kirtly Parker Jones from Obstetrics and Gynecology at University of Utah Health Care and this is The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: When I was a second-year medical student, I absorbed the idea that the womb was a perfectly safe place. I use the word absorbed because I don't think they taught that to me, I think I just figured that out. The placenta was the perfect mother, serving and protecting the fetus. Serving in that the placenta actively pumps some nutrients like to the developing fetus like oxygen and glucose. Protecting in that it keeps out large molecules and only smaller molecules can get in. Well, this was a rather romantic idea, but I was a rather romantic medical student.

By the time I was a third-year medical student, I was taught about congenital infections, infections in the child that start in the womb. Infections such as toxoplasmosis from uncooked pork and kitty litter, syphilis, well, from you know how. These aren't just molecules, these are whole organisms. They get through the placenta and into the fetus. We also learned about viruses such as chicken pox and rubella infecting the fetus. But in the dazed mind of a totally engaged but overextended third-year medical student, I never really questioned how they did that.

If the womb is a perfect mother protecting the fetus, how do those things get in? Well, first, it's important to remember that viruses are really sneaky. Here's a little bit on virus biology. They're just a little packet of DNA wrapped in a membrane. They don't have the ability to reproduce themselves. They get into cells and hijack the cell's energy and DNA and proteins and make the cell make more virus. The interesting part is that viruses are choosy. They have markers on their covering that attach to specific proteins on certain kinds of cells. Some viruses like the respiratory tract but not the skin. Some viruses like white cells, like the HIV virus.

The Zika virus, which has already found cells in the infected mother to turn into Zika factories, and the virus spreads throughout the mother's body. The virus then may specifically bind to the lining of the placenta, the amnion. Then the virus turns the amniotic membrane into a Zika virus factory. Then the Zika virus hatches out of the amnion cells into the fluid around the fetus and the fetus gets infected. Specifically, the virus likes nerve cells; it likes fetal brain cells. It binds the fetal brain cell, turns it into a Zika factory and then in the process it kills the brain cell.

There is another mechanism by which the Zika virus might get into the womb and that is through the leaky placental cells that are made early in development in the first trimester. The virus then seems to specifically attach to the stem cells of the embryonic brain. Destroying these cells, which have been infected by the virus, may explain why the findings of microcephaly, small brain, in some of the babies that were infected in pregnancy. The virus can get in at any time of pregnancy, but it's particularly successful and potentially damaging in the first trimester.

Researchers also found that different strains of the Zika virus were more infectious, more successful at hijacking placental cells than others. The earlier African strain was less infectious than the current South American strain, which is much more infectious and much more likely to infect the fetus. In fact, it seems it's not just spread through infection by mosquitoes, but it's spread sexually from men to women and now, we think, from women to men. There's the possibility that it might be spread from other body fluids as well.

Actually, it is remarkable that the placenta and the membranes can protect the fetus from as many viruses as it does. Only a few viruses that we know about specifically attack placental cells and then go on to infect and harm the fetus. The chicken pox virus, the measles virus and the cytomegalovirus are examples and we have vaccines for some of these. Understanding the mechanisms by which viruses can infect placental cells can help us develop anti-viral agents and other approaches to treatment.

Viruses are particularly successful and rapidly changing in their molecular appearance, meaning the way their face looks to different cells. So it may be difficult to make a vaccine. Or because the Zika virus belongs to a family of viruses that include Dengue yellow fever and we have a vaccine for some of those, we might be able to make a vaccine for all three or maybe not.

In the meantime, it's important to remember that a womb isn't a completely protected place. And the placenta isn't a perfect mother, letting in only the good in keeping out the bad. We need to remember to offer protection to pregnant women and women who might become pregnant from viruses, drugs and molecules in air and water pollution that can get through the placenta and affect the fetus. Thanks for joining us on The Scope.

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Dr. Gellner: One of the most common reasons a parent brings their children to the pediatrician is because they're concerned their child has an ear infection. I'll talk about the symptoms to watch for and what to do if your child does have one on today's Scope. I'm Doctor Cindy Gellner.

Announcer: Health tips, medical views, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Dr. Gellner: Parents come in all the time saying their child has been pulling on their ear and they know this means they have an ear infection. Well, not so fast. Kids pull on their ears for a lot of reasons, ear infections only being one of them. Other causes are teething, ear pressure from nose congestion or allergies, and because it just plain feels good, especially when kids are tired.

There are a lot of nerve endings in the ear and that's why it's such a popular place for massage therapists and acupuncturists to work on. So other than pulling, your child has no other symptoms. Ear infection? Maybe not. But say your child also has a fever, has had a cold for a while, isn't sleeping like they normally do and are just plain cranky, then it's time to get those ears checked out.

Despite what a lot of people think, going outside in the wind or cold without a hat on won't cause an ear infection. Ear infections happen behind the eardrum, not in front of it where the cold and the wind would hit. An ear infection is caused by bacteria and it's a common complication of a viral cold. Nasal congestion and mucus block off the tube that connects to the middle ear to the back of the throat. That's the Eustachian tube. And then the ears can't drain properly if that's blocked. This makes a pool of fluid, which is a great breeding ground for bacteria and, hence, an infection is born.

Sometimes, kids have what are called serous ear infections. That means there's fluid behind but it's not all gross, and this fluid usually goes away in a few months. This type of infection does not need antibiotics.

Kids between six months and two years are most likely to get ear infections, but they're actually pretty common until age eight when the internal anatomy of the ear starts to change and they aren't as prone to infections. Most kids will have at least one ear infection and over 25% of these children will have repeated ear infections. In a small percentage of children, the pressure in the middle ear fills with puss and that causes the eardrum to rupture and drain. It's usually just a small hole, which heals over the next three months.

Now, you find out your child does indeed have an infection, you need to be sure your child takes the antibiotics prescribed by the pediatrician and finish the entire course to make sure all the bacteria is treated. Tylenol and Motrin can also help with pain.

Some people talk about putting warm oil into the ear, but that's not a good idea. If the eardrum bursts, follow up in three weeks to make sure the infection is gone and the eardrum is healing. Ear infections seem like a rite of passage for some kids. I've had parents try looking in their child's ears with a flashlight to see if they have infections. Trust your child's ear exams to the experts. As pediatricians, we get really good at looking in ears and seeing if there truly is an infection or not.

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