likely to result in neutropenia Thrombocytopenia can be found with both diseases although severe thrombocytopenia is more common in dengue Fluid resuscitation may be needed due to dehydration from reduced intake and increased insensible losses Most children recover fully over a period of weeks but approximately 5% to 10% experience chronic joint symptoms Severe complications include meningoencephalitis, cardiopulmonary compromise, acute renal failure, and death; these are more common in patients with comorbidities and the elderly The primary diagnostic tool used is serology PCR can be performed at state labs and the CDC ELISA tests identify IgM (approximately days after infection, and IgM remains elevated for up to months) antibodies Management: Treatment is supportive Repeat episodes are more likely to be severe NSAIDs or corticosteroids may help to relive arthralgia Standard isolation precautions should be used The risk of human infection may be reduced by utilization of insect repellant (no more than 30% DEET recommended for children >2 months), wearing long pants and long sleeve shirts, and staying in screened or air-conditioned dwellings during peak feeding times Bed nets are ineffective since this mosquito genus is a daytime feeder Standard precautions are recommended Zika CLINICAL PEARLS AND PITFALLS Zika is endemic in the Americas and the Western Pacific While symptoms can mimic those of Chikungunya, symptom severity and duration are less intense and over 80% of individuals are asymptomatic Transmission can occur via mosquito bite, blood transfusion, and sexual contact Current Evidence The main vectors are Aedes species mosquitoes, which are daytime biters; as such, bednets are ineffective in preventing Zika infection While there was no documented Zika transmission in the United States in 2018, 56 countries have reported outbreaks in the last years, most from the Caribbean, Mexico, Central and South America, and the Western Pacific islands Goals of Treatment The symptoms of Zika infection can mimic those of other pathogens more common in industrialized and developing nations Prompt recognition can guide reproductive decision making and allow emphasis on further mosquito bite prevention to decrease local transmission Clinical Considerations Clinical recognition: The incubation period is to 14 days Up to 80% of persons have asymptomatic infection Symptoms are mild, usually resolving in less than week, and can include fever, arthralgia, conjunctival injection, and a nonpetechial rash Guillain-Barré syndrome has been reported Infants with congenital Zika infection can have microcephaly, microphthalmia or cataracts, contractures, tonal abnormalities, and intellectual disability Triage Considerations Clinical assessment: The differential diagnosis includes dengue and Chikungunya (both transmitted by the same mosquito vector), as well as measles, adenovirus, and Kawasaki disease For nonvertically acquired infection, the diagnosis is based on RT-PCR obtained within 14 days of illness onset Even in patients with mild symptoms, PCR confirmation may help guide conversations about contraception after infection In congenital infection, RT-PCR in serum and urine and serum IgM can confirm the diagnosis Management: Treatment is supportive NSAIDs should be avoided until dengue can be ruled out Standard precautions are recommended, and affected children should avoid insect bites to decrease the risk of local transmission Diarrheal Diseases CLINICAL PEARLS