Monday, February 25, 2013

Detailed Awareness Campaign On Scarlet Fever

Scarlet fever is an acute infectious disease, that is caused by group A b-hemolytic streptococcus, transmitted by an air-droplet way, characterized by intoxication, rashes on a
skin, tonsillitis, regional lymphadenitis, and strawberry tongue.

Etiology: group A b-hemolytic streptococcus (GABHS).

source of infection – ill person not only with scarlet fever, but other forms of  GABHS infections (sore throat, erysipelas, streptodermia).
infection is transmitted by inhalation of infected airborne droplets, rare with food and direct contact.
susceptible organism – children 2-9 years old.

Pathogenesis An entrance gate is the mucus membrane of the throat, seldom damaged skin, and maternity ways (at delivery).

Pathogenesis has three lines:
·       Toxic (toxically damage of cardiovascular, central nervous, endocrine systems).
·       Septic – primary inflammation in the place of infection (tonsillitis, secondary bacterial complication).
·       Allergic – sensibilization by GABHS proteins (depression of immunity leads to allergic complications – nephritis, arthritis, myocarditis, rheumatism).

Clinical presentation: Onset is usually acute and is characterized by a sore throat (often with dysphagia), fever (often above 39 °C), pharyngeal and purulent tonsilar exudates. Anterior cervical lymph nodes, particularly the jugular-digastric nodes just beneath the angle of the mandible, are tender and enlarged. Erythema of the soft palate is common, and an enanthema of “doughnut” lesions on the soft palate. Strawberry tongue. Other features are nausea and vomiting, headache, abdominal discomfort. One to two days later the rashes like “sandpaper” appears, first on the neck and then on the trunk and extremities till the end of the day.
The eruption is characterized by dusky red, blanching tiny papules that have a rough texture. Papules are usually absent on the face, palms, and soles, but the face characteristically shows flushing with circumoral pallor. On the body, the rashes are intensified in skin folds and at sites of pressure. In the antecubital and axillary fosses, linear petechias are seen with accentuation of the erythema (Pastia’s lines).
The exanthema usually lasts 4 to 5 days and then begins to desquamate, first on the face last on the palms and soles. Pharyngitis usually resolves in 5 to 7 days.

Clinical diagnostic criteria:
1. Latent period: a few hours – 7 days.
2. Initial or prodromal period (from the first signs of illness to rashes appearance):
up to 1-2 days
• acute beginning;
• toxic syndrome, hyperthermia;
• in the throat: pain, bright hyperemia, pin-point enanthema,
• catarrhal regional lymphadenitis (photo).


3.  Period of exanthema (rashes):
а) Phase of height (1 - 2 days)
• maximal intoxication, fever up to 39-40 °C;
• tonsillitis: bright hyperemia of the throat marked off a hard palate (photo 31), pinpoint enanthema, hypertrophied tonsils, catarrhal, lacunar (photo 32, 33), follicle (photo 34, 35) or necrotizing (photo 36) tonsillitis;
• regional lymphadenitis;
• pin-point rashes for a few hours spread all over the body, intensified on the front and lateral surface of neck, lateral surfaces of trunk (photo 37), abdomen (photo 38, 39), lumbar region (photo 40, 41), in natural skin folds (photo 42), on the red background of skin, typical intensified in skin folds with hemorrhagic elements (Pastia’s lines) (photo 43), a skin is rough (“sand paper” sign), pale perioral triangle (Filatov’s sign) (photo 44, 45);
• white dermatographia;
• coated tongue (photo 46) within 2-3 days clears up (photo 47, 48), on 4th - 5th day becomes “strawberry” (photo 49, 50);
• sympatic phase of “scarlet fever” heart (tones are loud, tachycardia, BP is elevated).

bright hyperemia of the throat marked off  a hard palate

pin-point enanthema

Follicular tonsillitis

Lacunar tonsillitis

Necrotizing tonsillitis

Typical rashes localization

pin-point rashes

Typical rashes localization

Typical rashes localization in skin folds

Typical rashes localization in skin folds

Pale perioral triangle

Coated tongue

Tongue begin to clear up

 Strawberry tongue

b) Fading phase:
• normalization of body temperature till 3rd - 4th day of the disease, decrease of the toxic syndrome;
• rashes and redness of the skin from 2nd - 3rd up to 6th day turns pale;
• throat: enanthema disappears from 2nd - 3rd day, hyperemia turns pale till 6-7 day;
• the sizes of lymphnodes normalized till 4th - 5th day;
• vagus-phase of scarlet fever heart (bradycardia, dilation of the cardiac dullness borders, systolic murmur on the apex, low BP);
• a tongue turns pale till 10th - 12th day, with enlarged follicles.

4. Period of recovery: from 2nd week (for 10-14 days)
• changes on the skin: flakes-like desquamation all over the body except palms and soles (where it is larger) (photo 51);
• tongue with enlarged follicles;
• the vagus-phase of scarlet fever heart continue for 2-4 weeks;
• rise sensitivity to the streptococcus infection, possibility of complications.
1. Form:
a) typical;
b) atypical:
• without rashes;
• effaced;
• extra pharyngeal (burns, wounds, post-natal, after operations, delivery);
• with aggravated symptoms (hypertoxic, hemorrhagic).
2. Severity:
a) mild;
b) moderate;
c) severe: toxic, septic, toxic-septic.
3. Course:
a) smooth;
b) uneven (relapses, complications).

By the character:
• are infectious (streptodermia (photo 50, 52), necrotizing tonsillitis (photo 36), secondary tonsillitis (photo 54), peritonsilitis (photo 53) peritonsilar abscess (photo 55), otitis, purulent lymphadenitis, sepsis);
• and allergic (rheumatism, myocarditis, arthritis, glomerulonephritis).
By the time of development:
• early (first week of the disease);
• late (2nd - 3rd week).
By the etiology:
• specific or primary (caused by the same streptococcus);
• secondary (caused by the other bacteria).



Peritonsilar abscess

Laboratory tests
1.     The diagnose is confirmed by throat culture with group A b-hemolytic streptococcus.
2.     Serology (antistreptolysin O, antidesoxyribonuclease B) with their grows in 2 weeks may be useful for documenting recent GABHS infection.
3.     The complete blood cell count is helpful: usually white blood cell count higher 12500 cells/mm3, neutrophyllosis, left shift, eosynophylia, elevated ESR ECG, CBC and urinanalysis on the 10th day after the disease began, and on 21th day for possible late complications diagnostic (nephritis, myocarditis).
Diagnosis example:
• Scarlet fever, typical form, exanthema period, severe (toxic) degree, complicated by the right side peritonsilar abscess.
• Scarlet fever, typical form, recovery period, moderate degree, complicated by the myocarditis.

Differential diagnosis: tonsillitis may be seen with diphtheria, mononucleosis, adenovirus, and micoplasm; rashes may be seen with measles, rubella, and pseudotuberculosis.

Evidences for obligatory hospitalization of patients with infectious exanthema
-         The severe form of disease, when appears need in undertaking of intensive therapy; patients with moderate forms at age before 3 years.
-         Sick children from families with bad social-home conditions, especially in the event of impossibility of their isolation to prevent infections transmission.
-         Absence of conditions for examination and treatment at home.
-         Sick children from closed children institutions.
Advantages of the home treatment
1.     Possibility of additional infection by hospital bacteria is completely excluded.
2.     Realization of individual care principle for sick child is more full.
3.     Avoiding stressful reactions, which could appear in case of hospital treatment.
Treatment in home conditions is possible
1.     In conditions of isolated flat.
2.     In case of satisfactory material position of the parents.
3.     In case of parents desire to organize individual care and treatment at home.
1. Bed regime during an acute period.
2. Etiological treatment for scarlet fever is:
a. In the mild case penicillin orally (penicillin V) for 10 days 50,000-100,000 EU/kg/day divided in 3-4 doses. Erythromycin (or another macrolides) is alternative antibiotic (30-50 mg/kg/day). The course of treatment is 10 days.
b. In the moderate case penicillin intramuscularly (penicillin G), the same dose as in the mild case. The course of treatment is 10-14 days.
c. In the severe case: cefalosporins of the 1st-2nd generation, klindamycin, vancomycin intravenously for 10-14 days.
3. Detoxication therapy:
a. In the mild case large amount of oral fluids.
b. In the moderate and severe cases – Glucose and saline solutions IV.
4. Antihistamines (in average doses) – pipolphen, suprastin, claritin, cetirizin.
5. Medicine which strengthens vascular wall (vit. C and PP: ascorutin, galascorbin)
6. Control of fever (when the temperature is more than 38.5-39 °C); in children before 2 mo and in case of perinatal CNS damage, seizures in the history, severe heart diseases – when the temperature is up to 38 °C with acetaminophen (paracetamol 10-15 mg/kg not often than every 4 hours (not more than 5 times per day) or ibuprophen 10 mg/kg per dose, not often than every 6 hours.
7. Local treatment with antiseptic fluids (gurgling), UV-insolation. Patient may go home from infection department not earlier the 10th day of the illness, in 10 days blood analysis, urinalyses, ECG must be done.

Prevention: isolation of the patient on the 10 days, but he mustn’t visit school until 22 day of the disease. Contact person (children before 8 years) must be isolated for 7 days (period of incubation).
Key words and phrases: scarlet fever, three lines of pathogenesis, Group A b-hemolytic streptococcus(GABHS), ”doughnut” lesions on the soft palate, rashes “sandpaper”, dusky red, blanching tiny papules, circumoral pallor. Pastia‘s lines, desquamate, purulent and allergic complications.

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