Trading a thumb injury for gastroenteritis

Recently, my cherubic and adventurous nearly 2-year-old daughter, who my son has endearingly nicknamed “Danger Baby,” brought my family to the local ED with a nasty thumb laceration. As is the case in many busy EDs across the nation, we had a bit of a wait before being seen by a provider, slowly moving through triage, then waiting room, and finally an examination bay. We saw broken bones, other cuts and bruises, and an array of runny noses, coughs and crying infants. While there, I think we used a half gallon of topical antiseptic gel as my children enjoyed the procession of patients and their families following the path we had taken as well.

When we get called back to the examination room, my daughter’s wound had finally stopped bleeding, after hours of compression bandaging. We cleaned up the wound, made sure there was no need for sutures, and had it redressed and headed home. I left thankful my daughter was doing so well, following what could have been a much more serious hand injury.

Fast forward about 36 hours later, at 1 a.m. … I wake to my daughter crying in her crib. When I get to her bed, I find vomit all over the bed. She continued to vomit at least once every 2 hours for the next 12 hours, making for a harried night and tired family.

Danger Baby strikes again, but this time it’s gastroenteritis!

As her vomiting improved, and while we focused on hydration, 24 hours later she developed diarrhea that lasted 2 days. Everyone did their best in the house to wash hands while singing the ABCs and applying liberal amounts of alcohol-based topical antiseptics. Despite our valiant efforts, Danger Baby’s 72-hour arc of illness led to exciting times for anyone in close contact with our family. First my son, then my wife, then grandma, then our nanny, followed by her husband, and perhaps the countless others in our community we may have unknowingly exposed.

While no definitive testing was done, the timing and constellation of symptoms and impressive contagiousness, this very likely was a norovirus infection, likely a result of Danger Baby running and playing in the waiting room area doing what Danger Baby does.

Norovirus is the name given to a group of “Norwalk-like viruses” and is estimated to be the cause of 60% of acute gastroenteritis cases in the United States. The average incubation period for norovirus gastroenteritis is 12 to 48 hours. Illness is characterized by what Danger Baby had, in addition to nausea and acute-onset vomiting, followed by watery, non-bloody diarrhea.

In older patients, like my wife, malaise, myalgias and headache are often seen. Notably, high-grade fever is not something typically seen with norovirus-associated gastroenteritis. Dehydration is the most common complication. Symptoms typically last in the range of 24 to 72 hours. Not everyone that is infected manifests symptoms, with 20% to 30% of infections being asymptomatic.

Norovirus demands respect with how contagious it can be, needing as little as 18 viral particles to cause infection. Infection can be transmitted through exposure to stool, direct person-to-person spread, and even respiratory droplets when caring for someone vomiting. It’s a hardy virus that tolerates freezing and temperatures upward of 140°F.

So what to do to prevent infection? Well, the best we have is avoidance of exposure, routine and effective hand washing with soap and water, and cleaning potentially contaminated surfaces. However, as Danger Baby has taught my family, you can do your best, but sometimes your best is not good enough.

More information for patient families and providers can be found on the CDC’s website (http://www.cdc.gov/features/Norovirus/).