CC (chief compliant): Patient presents to the centre with rash and vomiting
HPI: Eight years girl was brought to the clinic by her mother. The parent states that the child has a history of 10 days a sore throat and has developed a rash on the hands and feet for the last eight days. She also had abdominal pain and vomiting. However, the mother indicated that she was not vomiting because she had not seen her vomit since the child is in school during the day. This means that she could have vomited without mother noticing. After two days, the child developed fever and the rash spread to the trunk. She also had enlarged papillae with a strawberry-like appearance.
Current medications: Penicillin 10 mg/day, 10 mg ibuprofen every 6 to 8 hours
Immunizations: Fully immunized; she had received Menz-B and received ADT.
PMHx: At the age of six years, the patient was diagnosed with Epstein-Barr virus (EBV) and Streptococcus aureus skin infection.
Allergies: There were no known environmental, insects, food or drug allergies
Fam HX: Three brothers and one sister, as well as both parents, were alive and well. Her maternal grandfather died of cancer. There were no cases of diabetes and Ischemic heart disease.
Soc Hx: Social history indicated that the patient is socially active and engages in playing with other children at school and home. Lives with her two parents and two siblings; both male aged between 10 and 12 years.
General: Tiredness, feverish and feeling of general unwell
HEENT: Blurred vision, swollen face, sore throat, sore ears, snuffly nose. Neck lacks pain or stiffness.
Respiratory: Occasions of dry cough at night, SOB, no wheeze, no sputum.
Cardiac: No chest pain, dizziness or palpations, regular heart beat.
Gastro: Normal eating and drinking, experiences of vomiting, No diarrhea.
Integumentary: Hot and itchy with aches. She had Eczema during early childhood. No any other history of rash.
Lymphatic: Enlarged nodes
Vitals: Temp 39oC. HR17, HR 107, BP, 110/78mmHg, Ht 128.2, Wt 25.8, BMI 15.7 kg/m2.
General: The patient looked miserable, but she was alert. She was able to maintain eye contact and had fluent speech. She was clean, tidy and appropriately dressed for the winter cold. She appeared slim but appropriate for the given age.
HEENT plus neck: Examination of the throat showed that it was red. Tonsils were slightly enlarged with slight exudates. Kopliks and lymphodenopathy were nil. The tongue was red with whitish distally. The neck was supple.
The respiratory: Excellent and equal air entry without any wheeze or crepes.
Cardiac assessment: Regular rate and rythm for both S1 and S2
Gastro: The abdomen was soft and not tender without any masses.
Skin: Rush that felt itch and hot upon touch
Integumentary: The patient had mucolopatch rash spreading all over the body with confluent around the shoulders and the neck, and branching easily with no papules. The affected skin felt hot when touched. The patient had healthy eating and drinking. She lacked diarrhea and nausea.
Psychiatric: normal mood and effects
Lymphatic: showed enlarged nodes
Hematological: No bleeding and no bruises
Lab test and diagnosis: Serological test for Group A Strept positive, throat swab culture pending
Rash on the hands, legs, and neck: Rash is a common manifestation of skin diseases. At least 4.7% of children under the age of 13 years in the United States presenting with dermatological conditions complain of rash as the main symptom (AlKhater, Dibo, Al-Awam, 2016). A study by AlKhater et al, (2016) showed that in addition to dermatological problems other various conditions are associated with the occurrence of a rush on the skin. Infectious diseases account for about 25.2.2 % of all rushes. Genetic conditions are also associated with rash. The rash may be accompanied by vomiting, abdominal pain, fever, and enlarged papillae.
Group A Streptococcus causes possible Scarlet fever- Scarlet fever. The main signs are rush on the skin spreading from hands to the neck and can eventually cover the whole body. The rash is usually red. The tongue also becomes reddish. A sore throat, headaches, vomiting, and fever, as well as swollen lymph nodes, are also associated with scarlet fever. This form of infection is most common in children aged 5 to15 years (Fine, Nizet, & Mandl, 2012).
Possible rash related to Strep throat- the same bacteria that causes scarlet fever also cause the strep throat. Unlike scarlet fever, symptoms such as a sore throat in this condition are usually rapid and not gradual. Swallowing becomes relatively hard, and the rash is not that extensive (Worrall, Hutchinson, Sherman, & Griffiths, 2007).
Viral infections- Other possible diagnoses could be viral infections like measles, Epstein Barr Virus as well as rubella that cause similar signs.
Toxic shock syndrome- the signs in the patient mimics the ones observed in a patient with toxic shock syndrome, however, the patient lacks high fever of more than 40oC, hypotension and vaginal symptoms.
Physical examination involves checking clinical signs occurring on throat, tongue, and glands. A scoring system is used to measure the accuracy of the diagnosis of scarlet fever using clinical signs. The systems are designed in a way that allows the assigning of points based on the observed symptoms such as rash, cough, fever, tonsillar exudates, and swollen lymph nodes. McIsaac score and Centor score systems are the most common. The ratings are usually between 1 and 5 with the lowest score corresponding to the few signs. A patient with more clinical symptoms suggestive of scarlet fever assigned more score. A study conducted in the US by Fine, Nizet, & Mandl (2012) on 200,000 patients who were 3 years and above showed that individuals who scored a score of 0 had a possibility of only 8% for these patients testing positive using a throat swab, and those who scored 4-5 had a probability of more than 55%. The patient, in this case, showed several signs suggestive of scarlet fever. She had several symptoms such as rush, red tongue with whitish distally. Tonsils appeared enlarged with exudates. These signs give the patient a score of about 4 suggesting that she is likely to have scarlet fever.
Rapid antigen serological tests can also be used in the diagnosis of scarlet fever. These tests are generally faster and convenient but are less accurate due to the presence of related antibodies against group A streptococcus. This aspect may lead to a false positive test. The antibodies may also take longer to appear and hence cannot be detected in the early stages of the disease. The specific antibodies may take 7-28 days to occur. These tests have a higher specificity of up to 95%, and a positive test should be followed by swab culture for children and adolescents since they are in a higher risk of developing a rheumatoid fever which is a fatal complication of scarlet fever (Stewart et al, 2014). Culturing is not a requirement in adults since they are not at risk of rheumatoid fever. Serological test on the patient tested positive for group A streptococcus antibodies.
Throat swab Culture
Throat swab culture is the gold-standard test of confirming the presence of Group A Streptococcus that causes scarlet fever. However, this test takes several days to obtain results hence cannot be reliable for critical patients. A throat swab is collected by swabbing the tonsillar pillars while avoiding contamination from the tongue. The specimen is sent to the lab, and the isolation of group A streptococcus is interpreted as a positive result. The throat swab culture method has a higher sensitivity than the rapid antigen serological tests (Stewart et al, 2014). Streptococcus pyogenes was isolated from the swab.
The diagnosis was made based on clinical signs. Confirmation diagnosis was rapid serological tests followed by culturing to isolate the causative agent. A blood sample was taken for serological test and throat swabs obtained for culture. The two specimens were taken to the lab for analysis.
The first medication was penicillin 250 mg three times a day for ten days. Penicillin was discontinued since it was not working to clear the bacteria causing the disease. This assumption was proved by the persistence of rash and isolation of Streptococcus pyogenes from a throat swab. Penicillin has progressively become resistant to various microbes including streptococcus due to over-prescription. Penicillin has shown a resistance rate of more than 40% to Streptococcus pyogenes (Brook, 2013). Penicillin was substituted with Erythromycin 400 mg twice a day for ten days. This drug is more efficient than penicillin since it inhibits synthesis of proteins by blocking activities of transfer RNA. It is less common than penicillin and hence has not been used for a long time unlike penicillin which was the first antibiotic discovered, and thus erythromycin has a lower probability of resistance. Alternative medication was cephalexin 500 mg for four days.
The patient was advised not to attend school until she shows clinical improvement. Streptococcus pyogenes is highly contagious and can be transmitted to other children at school. Cases of outbreaks have been reported in schools hence the patient should stay at home to avoid acting as a source of an epidemic (Ryu & Chun, 2018). The patient should also adopt appropriate personal and environmental cleanliness. She should not be exposed to irritants or pollutants that can affect the throat to avoid complications. Low hygiene could also lead to secondary infections especially due to the creation of entry points of microbe through the rushes on the skin. If eating becomes painful, the patient should take soft food and take worm drinks to soothe the throat. Dehydration should also be considered to moisten the throat.
Review will be done after every two days to assess how the patient is responding to the treatment. The rash should be observed for fading signs indicative of improvement. A referral was also made to a dermatologist to assess the state of the skin and report on any possible dermatological commodities.
Scarlet fever is a common condition in children. Bacteria called Streptococcus pyogenes is the cause of scarlet fever. Traditionally, scarlet fever was treated using penicillin as the first choice of medication, but I have learned that resistance is becoming common leading to treatment failure. If I encounter a similar case in future, I will consider requesting an antibiotic susceptibility test after a throat swab culture. This test will test the isolated bacteria for sensitivity to commonly used antibiotics including penicillin. Such intervention will eliminate speculation while administering antibiotics leading to the prescription of the only effective drug. It will also reduce the cases of misuse of antibiotics which is associated with the increasing prevalence of antibiotics resistance.
AlKhater, S.A., Dibo, R., Al-Awam, B. (2016). Prevalence and pattern of dermatological disorders in the pediatric emergency service. Journal of Dermatology & Dermatologic Surgery, 21(1), 7-13.
Brook I. (2013). Penicillin failure in the treatment of streptococcal pharyngo-tonsillitis. Current Infectious Disease Reports, 15(3), 232-235.
Fine, A. M., Nizet, V., & Mandl, K. D. (2012). Large-Scale Validation of the Centor and McIsaac Scores to Predict Group A Streptococcal Pharyngitis. Archives of Internal Medicine, 172(11), 847-852.
Ryu, S., & Chun, B. C. (2018). Investigation of Scarlet Fever Outbreak in a Kindergarten. Infection &am...
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