106: Childhood Exanthems, Rabies, Mumps and Creating Stronger Memories

Hello and welcome to episode 106 of the Physician Assistant Exam Review Podcast. This week we’re going to be talking about childhood exanthems and almost wrapping up infectious disease. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review where we teach PA students how to dominate PA school and ultimately pass the PANCE and land their dream job, right? That’s the goal to be able to start treating patients and start getting paid for your services. That’s what everybody’s looking to do. So this show and the entire program I put together here is designed with that in mind.

It is not necessarily designed to teach medicine or treating patients. Although we do those things, that’s not really the goal here. The goal here is to get you through school and to get you through your PANCE and get you into the position that is going to make you fulfilled. That’s the goal of this, of what I do. With that being said, I’m excited about where 2023 is heading. I’m excited about what we’re doing here. Some of the things that are happening.

For example, this year, last year we launched the 33 Days to Pass the PANCE program, which was phenomenal and helped a ton of people boost their scores a surprising amount. It helped, and what we really wound up with is a lot of people who had failed their exams and then were looking for something different, a different way to approach things, a different way to go after the test. And a lot of those people were able to really move the needle quite a bit. So I’m adding in, you may or may not be aware, I’m adding in more of those cohorts this year. There’s going to be a total of six. The next one is going to launch February 1st. But what that means is it goes live February 1st.

And if you are interested, you need to be involved before then. There’s about a week period before that. This goes live January 11th, probably January 20th. Registration for that cohort is going to be closed, whether or not it is at capacity, because there are things that need to get done before we can get into that class. There are a couple things that people need to work through and understand before we start on February 1st. So anyway, where I started this was, I’m excited because I’m going to be offering six of those cohorts this year, which is really going to help a lot of people. In addition to that, I’m looking towards moving that program forward, moving it to help more students.

So if you are a faculty member and you have students who you believe are at risk, please don’t let them get to a point where they haven’t passed the exam. And then they have to search and find the things which I teach. Get in touch with me, reach out to me or have them reach out to me before that becomes a problem. And I’m happy to help. I’m happy to work with them. I have loads of programs, loads of stuff. And I’m certainly going to be building out more of that as the year progresses.

So that’s some of the stuff that’s happening here behind the scenes. Some of the things I’m working on and looking forward to is how to get a lot more of that information to people earlier on rather than just in the 33 Days program when people are starting to either take their PANCE or have already taken it and not gotten the score they wanted. But even earlier in their PA journey, when they find that some of their study habits need to change a little, some of their test taking habits need to change a little in order to get the grades that they deserve. And the best way to find out about all that stuff, by the way, is to sign up for the email list at physicianassistantexamreview.com, where you can absolutely and very easily get onto the email list, and then you will find out as things progress, as things come out, and you’ll hear about those as they’re happening.

All right, so today we’re going to be moving through infectious disease, going through the childhood exanthems. These are actually fairly easy. They seem more complicated than they are. And I believe that a lot of that has to do with the nomenclature that we use. It made sense at one point. Sometimes that happens when people first discover things. The nomenclature they choose is valuable and helpful.

But as time goes by, it makes a little bit less sense. So without further ado, let’s go ahead and jump into our priming questions and get started. A child presents with four days of fever and two small white spots in his mouth. What might those be? A child presents with four days of fever and two small white spots in his mouth. What might those be? Where does the rubeola rash begin?

Where does the rubeola rash begin? Is rabies curable? Is rabies curable? What is the best way to prevent the mumps? What’s the best way to prevent the mumps? And lastly, a patient presents with a lacy red rash on the face. And then any other context you want to add to that.

But that lacy red rash is going to be our key term there.

All right, those of you who are not familiar with the priming questions, the reason for those is to get your brain moving, to get your thinking, to get you to stop just listening as you drive or fold laundry or go for a run or whatever it is that you’re doing when you listen to the show. It’s to get you actively thinking and actively engaged. I want you to try to answer those questions as we move through because that’s one way to help make the material stick inside your brain.

Now, like I said, for the exanthems, the childhood exanthems, the nomenclature is a bit confusing and it’s because they were initially named, and I’m not going to go into the history of it. It’s just not going to be a use of our time here. But initially there were six childhood of exanthems. And exanthem just means widespread rash.

Now, initially, these were rubeola, scarlet fever, rubella, exfoliative staph infections, erythema infectiosum, and roseola. So there were six of them. I was trying to figure out why chickenpox isn’t included in this list, but I couldn’t come up with a reason. If you know, email me and let me know. I’m curious why that one would be left out. I don’t know if it’s just a, you know, we had one that was named, there was a reason or if it just wasn’t part of the mix yet, it’s hard to say. But it almost doesn’t matter.

The only place that this nomenclature matters that I’ve seen, and again, I’m more in surgery than in medicine or especially in pediatrics, but it’s fifth disease or fifth disease, which is erythema infectiosum, fifth disease. And then the other reason why this is hard is because things have multiple names. So rubeola is also known as measles and rubella is known as the German measles, right? That makes it harder. There isn’t more to know, but you need to know that information or else the rest of it’s impossible, right? So I would spend a ton of time making sure I knew that rubeola is measles and rubella is German measles. That will make life easier.

You know, I struggle. I moved into the town I live in almost 10 years ago and it drives me crazy because about, I don’t know, half the, I feel like half the roads here have one name at one end of the town and a different name at the other end of the town. And I never know what road I’m on after all this time of living here. The two names make this really hard. So the same thing, fifth disease and erythema infectiosum. We now have multiple names for the same diseases that we need to know. To me, you can make your life a whole lot easier if you spend some time memorizing those right out front, right out of the gate.

You know, just set up a post-it note on your mirror, on your cabinets, that just says, you know, rubeola on one side and measles on the other, rubella on one side and German measles on the other, fifth disease on one side and erythema infectiosum on the other. And I think that will help you considerably for this section. Because outside of that, the section is not incredibly difficult. The problem is that you have multiple names and that the diseases are similar. That’s what makes this section hard.

So let’s jump in. Rubeola, measles. First disease. It’s highly contagious, and it’s a respiratory droplet transmission. Usually wind up with a fever greater than 104, cough, runny nose, rhinitis and coryza, conjunctivitis. Here’s the key. The rash is the key to these, right?

The whole point here is that these are exanthems. The rash is the key. The description of the rash in the question is going to help you a lot. Is a red-flat maculopapular pruritic rash. Red-flat maculopapular pruritic rash. Beginning on the face and then spreading. It may also feel bumpy.

That’s the measles. Red-flat maculopapular pruritic rash. You may also find what are known as Koplik spots. These are pathognomonic for the measles and are seen two to three days after onset. You get these small white spots inside the mouth. There are laboratory tests here you could do, which are serum IgM and salivary IgA. Treatment, number one treatment is going to be prevention, right?

The MMR vaccination, measles, mumps, and rubella. If you have a patient who has this, there’s really not a whole lot to do. It’s supportive care and monitor for complications like bronchitis or pneumonia. So again, that wasn’t a whole lot to know about the measles. And we don’t see a lot of it, right, because of the vaccinations. They’ve been so effective. But what you’re looking for is a red flat maculopapular rash that begins on the face.

With a kid who’s sick with a fever of over 104. Rubella, German measles. This is caused by the rubella virus. It’s known as third disease. The other key to rubella is it’s one of the TORCHes. So 90% chance of passing this virus to a fetus and causing congenital rubella syndrome. So you can get some nasty issues with the mother passing this along to her fetus, right?

I’m not going to go through all of those here, but definitely be aware of that. And normally it’s transmitted through large droplets. Clinical presentation is another rash that begins on the face, but it’s a pink raised spots. So already, what’s the difference between measles and German measles? They look a lot alike, right? That’s why they’re called measles and German measles. The difference is that flat pruritic red rash versus a pink raised spots.

Both start on the face. So the starting on the face part doesn’t help you differentiate them. It’s those other things and the Koplik spots that will help you differentiate them. Here we have a fever, but only about 100 degrees. You can get a sore throat, fatigue, swollen glands, and joint pain in adults. Here, once again, prevention is going to be the number one key with the MMR vaccination, measles, mumps, and rubella is what that vaccination is, what MMR stands for. The vaccine here is a live version of rubella, though, so we do not give it to pregnant women if they test negative for antibodies.

Why don’t we give it to pregnant women? Because it’s one of the TORCHes. And if they wind up getting German measles or rubella and passing it to one of their children during delivery, it can be a major problem, right? If they pass it along, it’s a major issue. So they do not get the vaccination during pregnancy. Although an interesting thing, as far as my research said, there has not been a case of German measles who was declared eliminated by the CDC in the U.S. As of 2004.

If you have a patient who has this problem, it’s going to be supportive treatment. Although if it’s a congenital disease, it’s going to require significant management, as we talked very briefly about.

Next, we have erythema infectiosum, or fifth disease. This is a parvovirus B19. It’s also known as slap cheek syndrome. So there’s another name for you, right? That should help you to identify it. But the more names we add, the more things there are to remember. And that just refers to the lacy red rash that occurs on the cheeks in these patients.

It’s transmitted through respiratory secretions. And once the rash appears, the child is no longer contagious in this case. Clinical presentation. Initially, it’s a flu-like or cold-like symptoms, fever, headache, running nose. And then after those symptoms kind of are waning, you get a bright red lacy rash that appears mostly on the cheeks. It can then spread to the arms, trunks, and legs afterwards. Treatment here is going to be supportive care.

Roseola is next. Patients are usually six months to two years old, so they’re younger patients with roseola. Human herpes virus 6 and 7 are usually responsible here. Clinical presentation is a sudden high fever, up to 104. And here the rash occurs as the fever is getting better. This is a red rash which begins on the trunk and spreads to the legs and neck. It’s not itchy and lasts about two days.

And again, treatment here is going to be supportive care.

Okay, now we’re going to move along into the mumps. Mumps tend to be a childhood virus, although they can certainly affect any age group. They’re caused by the mumps virus. Any case should be reported to public health. The virus is spread through respiratory secretions in close contact with infected individuals. Complications include orchitis, which is a common one that you’ll mostly hear about, oophoritis, which is similar to orchitis, right? So you have an inflammation of the ovaries as opposed to the testes, but there is less of a problem, less pain, less of an issue with fertility and things down the road with oophoritis.

Now with orchitis, there’s not really a huge issue with fertility. It’s very rare, but the orchitis can be painful at the time of infection. You can also get pancreatitis and meningoencephalitis. Clinical presentation is generally speaking, it’s a fever, headache, muscle aches, painful swelling of the parotid glands, which is usually bilateral. So that’s our big key here. When you see a question about the mumps, you talk about swelling in the cheeks. You get painful swelling of the parotid glands, which is usually bilateral.

Labs and studies, typically clinical diagnosis. You can do PCR or serology. Treatment, once again, is going to be prevention, MMR vaccine, measles, mumps, and rubella, in case you forgot, and then supportive care, including fluids and over-the-counter pain meds.

Next, we have rabies. This is caused by the rabies virus. It’s found in the saliva of infected animals and is transmitted through bites or scratches. Don’t worry, my kids don’t think I’m funny either. Found in the saliva of infected animals and is transmitted through bites or scratches. The most common animals that transmit rabies are dogs, cats, and bats. And if left unchecked, it affects the central nervous system.

Clinical presentation. So there’s two things that happen here. Initially, we get some pain and paresthesia at the site of infection. You get a fever, headache, muscle aches, and fatigue. And then neurological symptoms kick in. Neurological symptoms get pretty bad pretty fast. You get agitation, confusion.

Hydrophobia is the one that stands out here. So that fear of water. You get hallucinations, paralysis, and then encephalitis. Again, the reason hydrophobia stands out is because you’re looking for things to separate it from other diseases. That’s something that can separate rabies from everything else. Same thing with the route of infection, right? Labs and studies.

So if you’re going to picture a question about this, they’re probably going to include, they may include hydrophobia, and they’re going to include something about, a bite or a scratch from an animal. You can do a skin biopsy with fluorescent antibody testing or PCR of body fluids or tissue samples to get a diagnosis here.

All right, treatment. This is important. Once symptoms occur, death usually occurs within three to 10 days. It seems relevant, right? And super important. There is a vaccination. It doesn’t go out to everybody.

It is given to people with at-risk occupations. Think veterinarians or people studying bats in caves. I don’t know. It is a human diploid cell rabies vaccine, HDCV. And it’s three IM injections given over just about a month. So on day zero, on day seven, and on day 21, that vaccination is given. That vaccination’s efficacy does wane with time, so it needs to be readministered.

I forget what the timeframes are on that. I don’t think it’s something that you’re going to need to know.

Now, post-exposure. If someone is bitten by an animal that is believed to have rabies, it needs to be treated immediately, right? We cannot wait for symptoms. You need to thoroughly irrigate the wound with soapy water and then give a rabies vaccine, and there’s a rabies immunoglobulin, which could also be given. Those treatments tend to be very effective, but if they’re not given, these patients get into trouble very, very quickly.

All right. That will wrap up our discussion of childhood exanthems, mumps, and rabies for today. We have one more discussion in infectious disease, and I think we wrap it up. I think that’ll be it, which is kind of exciting. I’d love to be closing out topics for the show and making these available to people. So that’s really great. Our study tip for today, and please, it’s funny how many people I hear from down the road who say, you know what, initially I skipped the study tips and I tried, I didn’t think they were important, and I just fast forwarded through them.

And what I found was once I started listening to them and implementing them, I started to do a whole lot better. So take that with a grain of salt and use it as you will. But today’s study tip is going to be about solitude. Solitude, the definition, and I wish I could remember where I found this. The definition I really like here is the freedom from input from other minds. Freedom from input from other minds. How much time throughout the day do you spend without some other mind influencing you, interacting with you?

So let’s call that listening to music, listening to podcasts, watching television. I include video games in there. Talking to someone else. How much time does your mind spend separated from other minds? And what I found is that your mind, all of our minds, need time and space to process things. If we are constantly bombarding our brain with new input, it doesn’t have time to organize and clean, right? Think about your notebooks or your desks.

If you just kept piling things in and piling things in and piling things in, there’s no time or space to organize and clean and get things ready. Your brain needs that time and space. Sleep is a major component of that. It’s my belief that that’s why it’s so important for memory because you’re categorizing and you’re moving boxes around within your brain while you sleep. But doing that during the day is also important. And you can take small amounts of time. Longer can be better, but simple things.

You know, people talk about meditation, and some people that has a strange connotation for some people, and some people struggle with the idea. But doing things like, you know, a lot of times if I’m cleaning around the house, I’ll have music on, or I’ll have a podcast on, or if I’m driving, I almost always have a book or podcast on. But once in a while, I turn it off. Once in a while, it’s just me. Or if I’m mowing my lawn or going for a run, most of the time I’ve got music or a podcast going. But once in a while, I shut that stuff down. And you’ll find if you don’t do this typically, the amount of ideas and the connections you can make in a very short period of time when you don’t have input from someone else is surprising.

And I believe it has a lot to do with why we struggle to retain more information. I know it does for me, and I can see it in my children. The constant inputs doesn’t give us a chance to really pay attention and think about and spend time on the things that have already been inputted, right? So we have information in our brains and we just get more and we move on. We get more, we move on. We get more, we move on. Spending some time in solitude, even if it’s not purposefully studying, even if we can’t see exactly what’s happening helps our brains to categorize and retain more information.

Give it a shot. This week, find some activities you normally do to music or with a podcast or with a book on tape and do it without that input. You know, it’s one of the reasons why, you know, think about, people talk about getting their best ideas in the shower, right? It’s called solitude. It’s called a little bit of distraction with the water and a little bit of distraction with an activity and the solitude.

All right, let’s answer our questions. What’s the best way to prevent the mumps? The MMR vaccine. Hopefully, you should be able to nail that one. Child presents with four days of fever and two small white spots in his mouth. What might they be? Koplik spots, which would be what disease?

Which we’ve had the mnemonic for what disease? The measles. Is rabies curable? Is rabies curable? It’s a little bit of a trick question. The answer is no, it is not. But it’s preventable even after the bite.

Right? We give the vaccination and we give the immunoglobulin and we prevent it even after the bite. A lacy red rash in the stem of a question in a kid should make you think of what? A lacy red rash should make you think of what disease? Erythema infectiosum or slap cheek or fifth disease are all the same thing.

All right. To me, that’s the big takeaway. Differentiate these diseases, figure out what’s different about them, how they present differently, how you have to pick them out differently, right? They’re basically the same treatments, except for rabies, of course, but they’re basically the same treatments. You’re going to be looking for the, you know, it’s going to be a, I don’t know why I’m struggling with the words now, supportive care. It’s going to be basically supportive care for most of these, right? So the questions you’re going to get aren’t going to be about treatments.

Most likely, they’re going to be about how you differentiate them as they walk into the office. How do they look different? How do those rashes present? Are they on the face? Are they on the arms? Are they on the chest? Are they itchy?

Are they bumpy? Are they lacy? Are they red? Are they pink? Are they flat? That stuff is what’s going to come out on your test. At least if I were writing test questions, which I think is just makes sense, right?

How else would you write them?

All right, so thank you so much for tuning in today. Really appreciate it. If you got something out of today’s show, absolutely please do me and someone else a huge favor by sharing the show with them. Let them know where you’re getting some of this amazing information from, where you’re getting the information that’s helping it stick in your brain and helping you get your way through PA school and to pass your PANCE. And as always, if you’re looking for more, more, just more, head over to the website, physicianassistantexamreview.com. Over there, you will find all of the show notes for every episode, including today’s episode and all the back episodes on there. And you can also sign up for the email list over there, which is going to get you daily emails from me with tips, tricks, and methods to make your way through PA school and hopefully make all of that a heck of a lot easier for you.

All right, take care. Great to talk with you again. I can’t wait to do this for our next session, a wrap-up infectious disease. Good luck on your exams.