Wednesday, June 12, 2024

Rotavirus

Practice Essentials

Rotavirus (see the image below) is one of several viruses known to cause a self-limited gastroenteritis. Fluid stool losses may be dramatic, and death from dehydration is not uncommon, particularly in developing countries.

Transmission electron micrograph of rotavirus. Ima

Transmission electron micrograph of rotavirus. Image courtesy of Centers for Disease Control and Prevention.

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Signs and symptoms

Symptoms of rotavirus infection usually begin within 2 days of exposure and include the following:

Anorexia

Low-grade fever

Watery, bloodless diarrhea

Vomiting

Abdominal cramps

Stool output can be copious during the diarrheal phase of the illness, and dehydration is a common presenting complaint.

See Clinical Presentation for more detail.

Diagnosis

The physical examination findings for rotavirus infection are often unremarkable except for signs of dehydration. Other findings on examination may include the following:

Hyperactive bowel sounds: Most common finding

Sunken eyes and/or anterior fontanelle

Dry or sticky-appearing mucosa

Rough skin or diarrhea-induced diaper dermatitis

Tachycardia: Can be disproportionate to the temperature

Rectal examination: May stimulate production of watery, heme-negative stools

Depressed sensorium

Weight loss

Significantly decreased urine output is an important sign. However, this may be hard to identify in diapered infants, because the massive watery stool output makes it difficult to determine the amount of urine output.

Laboratory testing

Rotavirus may be identified by the following means
:

Enzyme immunoassay (most common)

Latex agglutination

Electron microscopy

Culture

Other laboratory studies include measurement of electrolyte levels in patients with severe dehydration, alterations in mental status, associated seizures, or oral replenishment with excessive water or salt, as well as measurement of bedside glucose levels in very young infants and in any age child with associated lethargy.

See Workup for more detail.

Management

In most cases, no medication is required for rotavirus infection. Instead, attention should be directed to appropriate fluid intake and other conservative measures.

Supportive care

Supportive care in infants with rotavirus infection includes the following:

Ensuring a secure airway and breathing, identification of circulatory compromise, and maintenance of adequate circulation

Administering 20 mL/kg boluses of isotonic sodium chloride solution or Ringer lactate solution until volume restoration in infants who appear significantly dehydrated (A total requirement of 60-80 mL/kg is not uncommon.)

Maintaining hydration: Key issue for children who are not dehydrated; selection of an appropriate fluid is crucial (ideally, commercial infant solutions, such as Pedialyte and Rice-Lyte); small, frequent feedings work better in infants who are vomiting; after resolution of vomiting, administer standard soy-based infant formula

Administering supplemental feedings of oral maintenance solutions to infants with excessive fluid losses

Consideration of antiemetics for vomiting children older than 6 months

There are currently 2 FDA-approved rotavirus vaccines to protect against rotavirus gastroenteritis (ie, RotaTeq and Rotarix). These vaccines are indicated in infants aged 6-32 weeks (RotaTeq) and those aged 6-24 weeks (Rotarix).

Note that in June 2013, the FDA approved required labeling for RotaTeq regarding intussusception data from the Mini-Sentinel’s Postlicensure Rapid Immunization Safety Monitoring (PRISM) program, the largest vaccine safety surveillance program in the United States.
The Mini-Sentinel PRISM study identified an increased risk of intussusception in the 21-day time period after the first dose of RotaTeq, with most cases occurring in the first 7 days after vaccination. No increased risk was found after the second or third doses. The findings translate into 1 to 1.5 additional cases of intussusception per 100,000 first doses of RotaTeq.

The data from the Mini-Sentinel PRISM study regarding the risk of intussusception following the use of Rotarix were inconclusive.
Therefore, no labeling changes were required.

See Treatment and Medication for more detail.

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