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Colds, Flu, and When to See the Doctor

By Dr. Moghissi - October 2009

Fall is here, flu's and colds are going around, and fall allergy season is mixed in too. Most people know that there is no cure for the cold. But how does one know when it has become something more serious, needing an antibiotic? How do you even know it’s a cold, as opposed to allergies?

The Flu

It is definitely worthwhile recognizing the flu and treating it. Most people have a sudden onset fever (temperature over 101) with severe achiness, tiredness and feeling totally exhausted. They often wake up in the morning feeling fine, and within a few hours feel like they’ve been beat up. Headache and dry cough are common, but sore throat, stuffy nose, sneezing, nausea and vomiting can also occur.

There are medications to treat the flu, and if started within 48 hours of onset of symptoms, can significantly decrease the severity and duration of symptoms. The medication does not kill the virus, but stops its reproduction. Therefore, the sooner the medication is started, the more effective it will be.

Colds

A cold generally has a more gradual onset. It might take a day or more for it to get going. In adults there is usually no fever, or it will be low-grade-under 101. It is not unusual for children to have fevers with colds. There is often tiredness and weakness, but it is milder. Stuffy nose, sore throat, and congestion in the ears and chest are very common.

As far as I know, there are no medications to shorten the duration of the cold. I have seen medications advertised that claim to do this, but have not been able to find any evidence to back this up. There was a study published in the American Journal of Medicine in 2001 comparing Zinc nasal spray to placebo, which showed no difference between the two (except the Zinc group had slightly less severe symptoms the first day).

Using a decongestant (pseudoephedrine), does help with symptoms. It is not recommended to use antihistamines, as they thicken secretions and can make a sinus infection more likely. Cough medications can also be helpful.

Prevention is your best bet. Frequent hand washing seems to be the most effective method. Interestingly, a recent study found that using anti-bacterial soaps was no more effective than regular soaps.

Allergies

Allergies can have similar symptoms to a cold. There will be no fever, and tiredness and weakness will be mild (depending on the severity of the symptoms). Congestion, sore throat (often from a post nasal drip) and sneezing are also common. In addition, runny eyes and itchiness is often seen.

Allergies can be of sudden or gradual onset, or can be continuous. If you are allergic to cats and go to visit your sister who has three cats, you may have a sudden onset of symptoms. They should go away fairly quickly after you leave her house though. Seasonal allergies (pollens, grasses etc) tend to come on more gradually, over days to weeks. People who are allergic to dust and molds often have symptoms year round.

Confusion can occur when someone has a sudden or gradual onset of allergy symptoms. In principal though, allergies can be treated like a cold (at least in the short run), and time will help differentiate between them. Allergies do benefit from treatment with antihistamines and are not infectious, so it is beneficial to at least try to differentiate between them.

Secondary Infections

Most people go to the doctor when they think they have a secondary infection. This would include sinusitis, bronchitis, conjunctivitis (pink eye), pneumonia, and otitis media (ear infections, most commonly seen in children). Both sinusitis and otitis media can be a consequence of a cold or allergies. All can be either viral or bacterial and only bacteria can respond to antibiotics. Because of the problem with antibiotic resistance, there have been many studies done in recent years to try to decide what should and should not be treated with antibiotics. Unfortunately, there are still a lot of unanswered questions in this area.

Bronchitis is an inflammation in the lungs. Cough is the major symptom. Most bronchitis is viral, and does not respond to antibiotics. The exception would be in people who have underlying lung disease, primarily smokers and long time asthmatics. Sometimes a cough is the only symptom of wheezing. In that case it is often accompanied by shortness of breath, especially with activity, or the cough may just hang on longer than expected. That can (and often should) be treated, usually with an inhaler.

Pneumonia can really only be diagnosed by chest x-ray. Studies have shown we doctors are really bad at diagnosing it by just listening. Cough, fever, and severe fatigue are the most common symptoms. We usually treat people with antibiotics if they have pneumonia on chest x-ray, although many will be viral. It can take many months to recover from pneumonia.

Conjunctivitis is redness, itching and discharge in the eyes. It is also usually treated with antibiotics, although in the form of eye drops. Oral antibiotics work also, so we’ll usually skip the drops if we’re also giving antibiotic pills.

Otitis media is most often seen in children. It is a mechanical problem where the tube that connects the back of the ear drum to the back of the throat gets swollen shut. The fluid behind the drum can’t drain, causing pressure and often infection. As people get older (and bigger) the tube also gets bigger, and less likely to totally swell shut.

Most cases of otitis media will resolve without antibiotics. Unfortunately, some will progress into an infection of the mastoid bone (one of the bones in the ear), so we usually do treat this. Sometimes the ear drum will rupture, which allows the fluid to drain, curing the problem. The drum will usually heal up just fine, although it can leave scarring and compromise hearing.

Otitis media often occurs later in the illness. The child will be getting better, and then suddenly the fever will be back and he’ll be very uncomfortable. In the past, anesthetic ear drops have been used to try to help with the pain, but recent studies have shown that they are generally not helpful. Tylenol and ibuprofen seem to be the most effective. (Note: Aspirin should never be given to a child with a viral illness!)

Sinusitis occurs when the small holes (ostia) that allow the sinuses to drain get plugged. When there is a lot of congestion the area get swollen and the fluid in the sinuses get trapped (similar to what happens in otitis media). Symptoms include pressure over the face, pain in the upper teeth, headache and low grade temperature. There is usually thick colored discharge from the nose or going down the back of the throat. Sinusitis generally requires many days of congestion before it occurs. Usually, the victim will get a cold, will start getting better, and then they get hit with more congestion, more pressure (in the face) and thicker, more colored nasal secretions. This process will usually take a week or more.

A diagnosis can be made by the history and a physical exam, by a sinus cat scan, or by endoscopy (sticking a scope up there and looking – done by an ENT). In the past we treated pretty much all patients with suspected sinusitis with antibiotics. Recent studies have put that practice into question though, because of the high incidence of viral sinusitis most people will improve at the same rate with or without antibiotics.

We do know that using decongestants, either oral (pseudo ephedrine) or in the form of nasal sprays (such as Afrin or Duration) does give the patient some welcome relief. They open the ostia, allowing the sinuses to drain and relieving some of the pressure.

One last comment. There was a recent study looking at whether we should treat strep throat. Strep throat is caused by a bacterium, and is generally sensitive to penicillin. We treat for two reasons. The first is to make the patient well quicker, the second to prevent later complications like rheumatic heart disease. This study was done with children aged 4-15, and found that treating with penicillin had no impact on the duration or severity of the illness.

I hope this helps you better understand the reasons why we (your doctors) do what we do. Respiratory infections are very common, and very annoying. They cause a lot of disruption in people’s lives, and occasionally have very serious consequences. We must always try to find a balance between too much and too little treatment. A recent article found antibiotic use linked with breast cancer risk. Antibiotics are losing their effectiveness due to resistance from overuse. It is important we use antibiotics when necessary, but only when necessary. Please be patient with us, as we are all still learning.

Jasmine Moghissi, M.D.

Focus - Health Tips » Colds, Flu, and When to See the Doctor

Colds, Flu, and When to See the Doctor

By Dr. Moghissi - October 2009

Fall is here, flu's and colds are going around, and fall allergy season is mixed in too. Most people know that there is no cure for the cold. But how does one know when it has become something more serious, needing an antibiotic? How do you even know it’s a cold, as opposed to allergies?

The Flu

It is definitely worthwhile recognizing the flu and treating it. Most people have a sudden onset fever (temperature over 101) with severe achiness, tiredness and feeling totally exhausted. They often wake up in the morning feeling fine, and within a few hours feel like they’ve been beat up. Headache and dry cough are common, but sore throat, stuffy nose, sneezing, nausea and vomiting can also occur.

There are medications to treat the flu, and if started within 48 hours of onset of symptoms, can significantly decrease the severity and duration of symptoms. The medication does not kill the virus, but stops its reproduction. Therefore, the sooner the medication is started, the more effective it will be.

Colds

A cold generally has a more gradual onset. It might take a day or more for it to get going. In adults there is usually no fever, or it will be low-grade-under 101. It is not unusual for children to have fevers with colds. There is often tiredness and weakness, but it is milder. Stuffy nose, sore throat, and congestion in the ears and chest are very common.

As far as I know, there are no medications to shorten the duration of the cold. I have seen medications advertised that claim to do this, but have not been able to find any evidence to back this up. There was a study published in the American Journal of Medicine in 2001 comparing Zinc nasal spray to placebo, which showed no difference between the two (except the Zinc group had slightly less severe symptoms the first day).

Using a decongestant (pseudoephedrine), does help with symptoms. It is not recommended to use antihistamines, as they thicken secretions and can make a sinus infection more likely. Cough medications can also be helpful.

Prevention is your best bet. Frequent hand washing seems to be the most effective method. Interestingly, a recent study found that using anti-bacterial soaps was no more effective than regular soaps.

Allergies

Allergies can have similar symptoms to a cold. There will be no fever, and tiredness and weakness will be mild (depending on the severity of the symptoms). Congestion, sore throat (often from a post nasal drip) and sneezing are also common. In addition, runny eyes and itchiness is often seen.

Allergies can be of sudden or gradual onset, or can be continuous. If you are allergic to cats and go to visit your sister who has three cats, you may have a sudden onset of symptoms. They should go away fairly quickly after you leave her house though. Seasonal allergies (pollens, grasses etc) tend to come on more gradually, over days to weeks. People who are allergic to dust and molds often have symptoms year round.

Confusion can occur when someone has a sudden or gradual onset of allergy symptoms. In principal though, allergies can be treated like a cold (at least in the short run), and time will help differentiate between them. Allergies do benefit from treatment with antihistamines and are not infectious, so it is beneficial to at least try to differentiate between them.

Secondary Infections

Most people go to the doctor when they think they have a secondary infection. This would include sinusitis, bronchitis, conjunctivitis (pink eye), pneumonia, and otitis media (ear infections, most commonly seen in children). Both sinusitis and otitis media can be a consequence of a cold or allergies. All can be either viral or bacterial and only bacteria can respond to antibiotics. Because of the problem with antibiotic resistance, there have been many studies done in recent years to try to decide what should and should not be treated with antibiotics. Unfortunately, there are still a lot of unanswered questions in this area.

Bronchitis is an inflammation in the lungs. Cough is the major symptom. Most bronchitis is viral, and does not respond to antibiotics. The exception would be in people who have underlying lung disease, primarily smokers and long time asthmatics. Sometimes a cough is the only symptom of wheezing. In that case it is often accompanied by shortness of breath, especially with activity, or the cough may just hang on longer than expected. That can (and often should) be treated, usually with an inhaler.

Pneumonia can really only be diagnosed by chest x-ray. Studies have shown we doctors are really bad at diagnosing it by just listening. Cough, fever, and severe fatigue are the most common symptoms. We usually treat people with antibiotics if they have pneumonia on chest x-ray, although many will be viral. It can take many months to recover from pneumonia.

Conjunctivitis is redness, itching and discharge in the eyes. It is also usually treated with antibiotics, although in the form of eye drops. Oral antibiotics work also, so we’ll usually skip the drops if we’re also giving antibiotic pills.

Otitis media is most often seen in children. It is a mechanical problem where the tube that connects the back of the ear drum to the back of the throat gets swollen shut. The fluid behind the drum can’t drain, causing pressure and often infection. As people get older (and bigger) the tube also gets bigger, and less likely to totally swell shut.

Most cases of otitis media will resolve without antibiotics. Unfortunately, some will progress into an infection of the mastoid bone (one of the bones in the ear), so we usually do treat this. Sometimes the ear drum will rupture, which allows the fluid to drain, curing the problem. The drum will usually heal up just fine, although it can leave scarring and compromise hearing.

Otitis media often occurs later in the illness. The child will be getting better, and then suddenly the fever will be back and he’ll be very uncomfortable. In the past, anesthetic ear drops have been used to try to help with the pain, but recent studies have shown that they are generally not helpful. Tylenol and ibuprofen seem to be the most effective. (Note: Aspirin should never be given to a child with a viral illness!)

Sinusitis occurs when the small holes (ostia) that allow the sinuses to drain get plugged. When there is a lot of congestion the area get swollen and the fluid in the sinuses get trapped (similar to what happens in otitis media). Symptoms include pressure over the face, pain in the upper teeth, headache and low grade temperature. There is usually thick colored discharge from the nose or going down the back of the throat. Sinusitis generally requires many days of congestion before it occurs. Usually, the victim will get a cold, will start getting better, and then they get hit with more congestion, more pressure (in the face) and thicker, more colored nasal secretions. This process will usually take a week or more.

A diagnosis can be made by the history and a physical exam, by a sinus cat scan, or by endoscopy (sticking a scope up there and looking – done by an ENT). In the past we treated pretty much all patients with suspected sinusitis with antibiotics. Recent studies have put that practice into question though, because of the high incidence of viral sinusitis most people will improve at the same rate with or without antibiotics.

We do know that using decongestants, either oral (pseudo ephedrine) or in the form of nasal sprays (such as Afrin or Duration) does give the patient some welcome relief. They open the ostia, allowing the sinuses to drain and relieving some of the pressure.

One last comment. There was a recent study looking at whether we should treat strep throat. Strep throat is caused by a bacterium, and is generally sensitive to penicillin. We treat for two reasons. The first is to make the patient well quicker, the second to prevent later complications like rheumatic heart disease. This study was done with children aged 4-15, and found that treating with penicillin had no impact on the duration or severity of the illness.

I hope this helps you better understand the reasons why we (your doctors) do what we do. Respiratory infections are very common, and very annoying. They cause a lot of disruption in people’s lives, and occasionally have very serious consequences. We must always try to find a balance between too much and too little treatment. A recent article found antibiotic use linked with breast cancer risk. Antibiotics are losing their effectiveness due to resistance from overuse. It is important we use antibiotics when necessary, but only when necessary. Please be patient with us, as we are all still learning.