Saturday, October 25, 2014

Ebola ? Worry About This Instead

                 As regular readers know, my daughter has been a juvenile diabetic since age 9. (Which was 1993)    No, she is not overweight. She will never outgrow this, and losing weight or any such life change or magic will never impact the fact that she will never make insulin herself again.  She does not have Type II diabetes, the current scourge of the United States, she has the rarer autoimmune variety which afflicts about 10% of diabetics, and is actually a different illness than the Diabetes Mellitus Type II which is so common now.        How did she get it ?    We do not know how all cases of Type I autoimmune diabetes mellitus start, but we do know this information, in her particular case.

                   When my daughter was 9, my father-in-law caught a virus in his office.  (He was in his fifties and worked as a engineer in a large office in the city.)   Within several days he became ill enough to be hospitalized with pneumonia, cardiac arrhythmia, and  generally was miserable with a flu-like illness.   The doctors thought he would be released by Monday, but he thought he was dying.  It turned out,  he was correct.  Despite being in a cardiac monitored intensive care stepdown unit,, he coded and died as the physician in charge was actually watching the monitor, and could therefore start attempts at resuscitation immediately.  Since this was an unexpected death, the hospital paid for a full autopsy and the results were surprising.   The causative organism to his flu was Coxsackie B4, which among other things, can invade the heart's conduction system and cause death, just as it did in this case.   We were all in shock as we made funeral arrangements, and many of the people where he worked came to the funeral although I noted many of them were sick or recovering from a viral illness also.   None of our physicians indicated that there may be implications for our family, and no one asked us about the health of the rest of our family or our kids.  They had the sniffles, but nothing more.

                 During the viewing, a room was set up in another part of the funeral home for the family and especially the kids. There was a television  and food was set up there.   In a very brief period of time, our daughter who had the sniffles downed quite a bit of soda,  and ate quite a bit.   Each time we checked on her, she seemed to be in the bathroom a great deal. This was quite uncharacteristic for her.and so I called the pediatrician to report rapid onset   polydipsia, polyuria and polyphagia,** all things that indicated that new onset Type I Diabetes Mellitus needed to be ruled out.  The pediatrician thought this was a grief reaction and tried to discourage our coming in.  When I called later to report a flushed face with a fever, she agreed to "let us be reassured" by the pediatric endocrinologist.  The endocrinologist thought she looked great and took blood for thyroid testing, but declined to get even a blood sugar. He proclaimed that she was simply in a growth spurt.  I was not okay with this. I wanted diabetes ruled out even though no one in my family had ever had it   So, on the way back from the endocrinologists office, I bought an inexpensive screening test kit at the CVS Pharmacy for glucose and sugar in urine. We didn't have to wait long on our return home to check it.  It was highly positive for glucose and ketones.  I took the time to explain to my daughter that there was no other reason this could be true that I knew of, other than a new case of juvenile diabetes.  I also told her that blood glucose monitoring devices and that teeny insulin syringes and improvements in technology have made this a much easier disease to control than it was even a few years prior.  I also told her that between the two of us, we could control it, and that after a brief hospitalization, she would give all her own insulin.  She accepted this, and while she went to pack and get her teddy bear, I called the endocrinologist and the pediatrician to arrange the inpatient emergency hospitalization.

                 The endocrinologist was flabbergasted that a parent who called his attention to something was actually correct.  "I should have listened to you, because you are a nurse !"  he said.  " That's not why you should have listened to me", I said.   When any parent tells you that something is really wrong with their child, then you should listen, because the parent is the expert historian on their child."    When my daughter was admitted to the hospital with a glucose level of 547,  (70-120 being the desirable range.)   we were told that she likely escaped death in her sleep because we had acted so quickly.   When I brought up whether this could have anything to do with the virus that had killed my father-in-law just a few days before, initially I was pooh-poohed.   My daughter's fever made it harder for them to brush me off.    Eventually the labs were done which indicated that my daughter too, had Coxsackie B4, and that it had likely activated the autoimmune chain of events which wiped out her ability to make insulin on the beta cell level.     I did not know of Coxsackie B4 virus at the time, but I learned that it can both invade the conduction systems of hearts and cause lethal arrhythmias, or it can cause a cascading effect which can cause the patient to attack and destroy their own beta cells, the functional unit in the Islets of Langerhans in the pancreas.  Both my father-in-law and my daughter were severely impacted by the same virus !  The link between viral exposure and Type I diabetes has been known for 40 years, yet is seldom discussed, even by nurses or physicians.

              This leads me to my concern in the present day.   While many are obsessing about Ebola, they are ignoring Enterovirus, which is much more common and much more easily transmissible.  A large nationwide study in Taiwan, published recently, indicates that children with enterovirus have a whopping 48% increased likelihood of developing Type I (autoimmune, juvenile) diabetes mellitus !    This is the first such study of its kind and the implications to the world are staggering.  No antiviral strategies are yet effective against it.   The article postulates that perhaps we can develop a vaccine for Enterovirus to try to head off some of these cases of Type I diabetes mellitus that will be heading down the pike. We are already seeing an increase in the incidence of the Type I variety of diabetes mellitus.   Learning to control this chronic illness is time consuming, expensive, and it can be life limiting. Not all of the children who develop it, survive. This needs to be a major focus of public health.

    So, think a bit about taking your baby or young child out to crowded places.   The old strategy of masks on visitors to babies, and frequent handwashing is a good one.  Perhaps a smaller daycare is a better idea than a large one.Perhaps having someone who does good daycare for only two children in her home has merit. Perhaps you are one of the lucky ones who can sidestep all the germs and viruses in daycare altogether.  Can you or your wife work from home ? Can one of you stay home with your young child ?

             Before you bet the farm on bugging out due to Ebola, please realize that there are far more common and more likely infections out there, which can be physically and financially devastating, and can change your child's life and your own forever.

                As for my daughter, it was hard work for us all controlling her blood sugars, even with the insulin pump she eventually received.   She grew up, went to college, graduated with honors,  drives a car, and has a life partner and a new home.  She has survived the birth and  the first month of her own new baby's life.   She realizes how layered viral exposures can adversely impact her child's life and is taking steps to limit those exposures.  I don't think my daughter will be taking her baby to the Coliseum to watch Sesame Street on Ice, as I did when the kids were toddlers.   She uses a pediatrician where sick children are segregated from those who are ill as they all wait.   Please think about doing the same. We need to do more to keep our children from layered viral infections.

**  Polydipsia means drinking liquids a great deal, polyuria means urinating frequently and in larger amounts, and polyphagia means eating a great deal.  These are earmarks of new onset diabetes, especially Type I.

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