SCARLET FEVER
Aim: To know diagnostic criteria of scarlet fever in children, how to examine the child with scarlet fever and prove the diagnosis, differentiate, give individual treatment and prophylaxis.
Professional motivation Due to nonspecific prophylaxis, antibacterial therapy of scarlet fever during last 50-60 years - the number of patient with severe forms of this disease had decreased. But total morbidity is still high. Number of patients with mild scarlet fever, repeated cases of it has increased. That is why it is hard to put diagnosis in time. It leads to widely spreading of streptococcal infection. That's why it is necessary for future doctors to know peculiarities of clinical features, treatment, and prophylaxis of scarlet fever.
Basic level:
1. To know how to ask complaints, disease history and life history in children (Propedeutic pediatrics).
2. To perform the clinical examination of the child (Propedeutic pediatrics).
3. To know microbiology, pathophysiology and pathomorphology.
4. To diagnose scarlet fever after clinical and laboratory examination (Infectious diseases, Propedeutic pediatrics, microbiology, pathophysiology).
5. To give etiologic, pathogenetic, symptomatic treatment (pharmacology).
Students' Independent Study Program
Objectives for students' independent studies
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
1. Etiology, epidemiology and pathogenesis of scarlet fever.
2. Clinical diagnostic features of scarlet fever.
3. Laboratory examination of patient with scarlet fever.
4. Differential diagnosis of scarlet fever.
5. Main treatment of scarlet fever.
6. Prophylaxis of scarlet fever.
Scarlet fever is an acute infectious disease, that is caused by group A β-hemolytic streptococcus, transmitted by an air-droplet way, characterized by intoxication, rashes on a skin, tonsillitis, regional lymphadenitis, and strawberry tongue.
Etiology: group A β-hemolytic streptococcus (GABHS).
Epidemiology:
- 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 atrium is the mucus membrane of the throat, seldom damaged skin, and maternity ways (at delivery).
Pathogenesis has three lines:
1. Toxic (toxic damage of cardiovascular, central nervous, endocrine systems).
2. Septic - primary inflammation in the place of infection (tonsillitis, secondary bacterial complication).
3. 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 than 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 (photo 29),
• catarrhal regional lymphadenitis (photo 30).
3 Period of exanthema (rashes):
a) 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), pin-
point enanthema, hypertrophied tonsils, catarrhal, lacunar (photo 32,33), follicular (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 dermographism;
• 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).
b) Decrement 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 - 3 rd up to 6th day turns pale;
• throat: enanthema disappears from 2nd - 3 rd day, hyperemia turns pale till 6th - 7th day;
• the sizes of lymphnodes are normalized till 4* - 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.
Classification
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) nonsmooth (relapses, complications). Complications
By the character:
• are infectious (streptodermia (photo 50, 52), necrotizing tonsillitis (photo 36),
secondary tonsillitis (photo 54), peritonsillitis (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).
Laboratory tests
1. The diagnose is confirmed by throat culture with group A β-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, neutrophilia, left shift, eosynophilia, 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 mycoplasma; rashes may be seen with measles, rubella, and pseudotuberculosis.
Oral mucous membranes | Hyperemied, friable, enanthema, Koplick's spots | Clear, sometimes single elements of enanthema | Marked off, bright hyperemia, enanthema on palate, tonsillitis |
Intoxication | Significant, lasts 5-7 days | Mild or being absent | Proportional to local signs, short for 1-3 days |
Other symptoms | Complications (respiratory, digestive, nervous, urinary systems, eye, ears, skin) | Increased and painful posterior neck and occipital lymph nodes | Tonsillitis, changes on the tongue (coated tonque, from 4-5th days -"strawberry"), complications on 2nd-3rd weeks |
Laboratory criteria | Leucopenia, lymphocytosis, aneosynophilia, serological reaction with measles antigen (+) | Leucopenia, lymphocytosis, increase of the plasmatic cells' number, serological reactions with rubella antigen (+) | Leucocytosis, shift to the left, neutrophilia, enlarged ESR, in pharyngeal, nasal swabs - streptococci |
Signs | Pseudotuberculosis | Meningococcemia | Chickenpox |
Initial symptoms | Acutely with many symptoms (intoxication, intestinal changes, seldom -catarrhal signs | Intoxication, develops very acutely, initial measles-like rash on lower limbs | Acutely, with intoxication, rash |
Time of the rashes' beginning | On 2nd-8th day | First hours of the disease | On lsl-2rd days, appear next 3-5 days as pushes |
Morphology | Point-like, small spots, erythema | Hemorrhagic, "starlike" with necrosis in the centre | Polymorphic (spots, papules, vesicles, crusts) |
Sizes of elements | Small, middle, large | From small to significant | Middle |
Localization | "Hood", "mitten", "socks" signs, in skin folds, bends, around joints | Buttocks, lower limbs, less - on trunk, arms, face | On whole body, on hair part of the head, seldom - on palms and soles |
Brightness and color of elements | Bright | Hemorrhagic, bright, sometimes cyanotic | Papules are pink, vesicles - on hyperemied base |
Further rashes' development | Gradually disappear for 2-5 days, desquamation | Small, disappear gradually, significant, leave "dry" necrosis | After desquamation of the crusts - a slight pigmentation |
Catarrhal phenomena | Not typical | Are absent, in 30-40 % on previous 2-3 days -nasopharyngitis | Not typical |
Oral mucous membranes | Possible hyperemia of the pharynx, tonsils, | Hyperemia and groiness of back pharyngeal wall, hypertrophy of follicles | On pink background -polymorphic elements |
Intoxication | Severe, long-lasting (2-3 weeks) | Very severe | Small or moderate |
Rashes | Absent | Pin-point, red | Macular-papulous may be erythema in 70-80 % of patients, who take semisynthetic penicillins | Absent |
Toxic sign | Proportional to the surface of the inflammatory process (mild, moderate or severe) | Severe in the first days | Prolong with gradual development (moderate or severe) | Moderate or severe in the first days |
Subcutaneous fat edema | Typical for toxic forms | Absent | Over the regional lymph nodes in severe cases | Absent |
Changes on the tongue | Coated | Coated, strawberry from the 4-5,h day | Coated | Coated |
Evidences for obligatory hospitalization of patients with infectious exanthema
1. The severe form of disease, when intensive therapy is need; patients with moderate forms at age before 3 years.
2. Sick children from families with bad social-home conditions, especially in the event of impossibility of their isolation to prevent infections transmission.
3. Absence of conditions for examination and treatment at home.
4. 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 complete.
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.
Treatment
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: cefalosporinsof 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), U V-irradiation.
Patient may go home from infectious department not earlier the 10* day of the illness, in 10 days blood analysis, urinalyses, ECG must be repeat.
Prophylaxis: isolation of the patient on 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 β-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.
Tests and assignments for self assessment
Multiple chose. Choose the correct answer /statement:
1. The symptoms of "scarlet fever" heart sympatic-phase appear in:
A. In prodromal period
B. First two days of exanthema period
C. On 3rd-4th days of exanthema period
D. From the second week of exanthema period
E. Only in the period of recovery
2. Choose septic complications of scarlet fever:
A. Encephalitis, otitis, myocarditis
B. Otitis, purulent lymphadenitis, necrotizing tonsillitis
C. Myocarditis, nephritis, arthritis, rheumatism
D. Synovitis, encephalitis, otitis.
E. Myocarditis, nephritis, necrotizing tonsillitis
3. Indicate the typical changes in the blood test in scarlet fever:
A. Leucopenia, lymphocytosis, elevated ESR
B. Leucocytosis, lymphocytosis, elevated ESR
C. Leucocytosis, neutropenia, normal ESR
D. Leucocytosis, monocytosis, elevated ESR
E. Leucocytosis, elevated ESR, eosynophilia
4. For the typical scarlet fever is characteristically:
A. The prolonged period of fever precedes the rashes eruption
B. The Koplick's spots appear two days before the rashes period
C. Semisynthetic penicillins provoke the rashes eruption
D. New elements of the rash are accompanied by the increase of body temperature
E. Skin desquamates on the second week after the rashes appear
5. When the child, who had scarlet fever, may visit the school?
A. On 6 th day from the disease beginning
B. On 10 th day from the disease beginning
C. On 15 th day from the disease beginning
D. On 22th day from the disease beginning
E. On 30th day from the disease beginning
6. Typical rashes for scarle't fever are:
A. Hemorrhagic
B. Maculous-papulous, predisposed to confluence
C. Small macules
D. Pin-point
E. Polymorphic (spots, papules, vesicles, crusts)
7. A boy 12 years is treated in the infectious department because the severe scarlet fever. How many days will last quarantine in his class?
A. 7 days
B. 15 days
C. 21 day
D. 30 days
E. It is not needed to impose the quarantine, only it follows to do the medical inspection of his classmates
8. How long the symptoms of "scarlet fever" heart vagus-phase continue?
A. 2 days
B. 5-6 days.
C. 10 days
D. 2 weeks
E. 3-4 weeks
9. What investigations is it necessary to appoint on the 20-21st day of scarlet fever?
A. Complete blood analysis, urinanalysis, ECG
B. Pharyngeal smear
C. Blood culture
D. Ultrasonography of the heart, ECG, ultrasonography of abdominal organs
E. Smear from the nose and throat on BL
10. What is the dose of benzyl penicillin at the scarlet fever?
A. 10-15 mg/kg/day
B. 100 mg/kg/day
C. 25-50 thousand IU/kg/day
D. 50-100 thousand IU/kg/day
E. 100-200 thousand IU/kg/day
Algorithm of practical students' work
Complaints and anamnesis taking in newborns and infants
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with the parents of sick child.
5. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).
Complaints and anamnesis taking in toddlers and preschoolers (children aged from 1 to 6 years)
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. By means of game playing find a contact with a child.
5. Tactful and calm conversation with the parents of sick child.
6. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).
Complaints and anamnesis taking in school age children
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with sick child his/her parents
5. Explanation of further steps to child and his/her parents (hospitalization, some methods of examination, etc.).
1. To ask complaints:
• fever, malaise, poor appetite;
• pain in a throat;
• rashes.
2. To ask anamnesis of the disease, epidemiological anamnesis:
• acute beginning from the fever, toxic syndrome, sore throat, time of the rashes appear;
• contact with a patient with streptococcal infection within 7 days.
• Conversation accomplishment.
3. To inspect a patient:
Physical methods of examination of newborns and infants
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Prepare for examination(clean and warm hands, warm phonendoscope, etc.).
Physical methods of examination of toddlers and preschoolers
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Find a contact with a child; try to gain his/her confidence.
6. Prepare for examination(clean and warm hands, warm phonendoscope, etc.).
Physical methods of examination of school age children
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Find a contact with a child; try to gain his/her confidence.
6. Prepare for examination (clean and warm hands, warm phonendoscope, use the screen if necessary etc.).
A. Examination:
• hyperemia of skin, pallor of perioral triangle, pin-point rash (on a red base of the skin,
intensified in folds, on the lateral surfaces of neck, trunk, lumbar region, lower part of abdomen), description of dermographysm;
• changes in the throat (marked off hyperemia of the throat from a hard palate, pin-point
enanthema, hypertrophied tonsils, tonsillitis: catarrhal, follicular, lacunar, necrotizing);
• a tongue is coated, "strawberry".
B. Palpation: enlarged anterior cervical, submandibular lymph nodes.
C. Percussion: dilation of cardiac dullness borders.
D. Auscultation: tachycardia, arrhythmia, deafness of heart tones, systolic murmur on an apex. Conversation accomplishment.
Informing about the results of examination
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a child and his/her parents what examinations should be performed and obtain their informed consent.
5. Involve adolescent and his/her relatives in to the conversation (compare present examination results with previous ones, clarify whether your expectations are clear for them or not).
6. Conversation accomplishment.
4. To estimate the results of additional researches:
• Complete blood analysis: eosynophilia, leucocytosis, neutrophilia with a shift to the left,
the increased ESR.
• Urinalysis: proteinuria, leucocyturia, erythrocyturia, casts, (infectiously-toxic damage of
kidneys).
• Throat culture: streptococci in the pharyngeal swab.
• Serology: AR, 1HAR, CBR with specific diagnostic test systems, growth of antibodies titre
in the dynamics.
• Explaining the results of examination to child's parents.
• Conversation accomplishment.
5. To substantiate the diagnosis.
Planning and prediction of conservative treatment results
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to child's parents the necessity of further treatment directions correctly and accessibly.
5. Discuss with parents and their child the peculiarities of drug intake, duration of usage.
6. Side effects and find out whether they understand your explanations.
7. Conversation accomplishment.
6. To prescribe the treatment: regime, diet, antibiotics, antihistamines, detoxication, corticosteroids (in severe cases), multivitamines, and symptomatic therapy.
Informing about treatment prognosis
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Correct and clear explanation of expected results of treatment.
5. Discuss with the parents and their child the importance of continuous treatment, following the treatment scheme; make sure that your explanations are properly understood.
6. Conversation accomplishment.
Step
1. The child, 5 years old, became ill acutely, 3 days ago. The body temperature has increased to 38 °C. He was treated by home methods. In 3 days his condition was not better. The patient was examined by family doctor. Pharyngeal and tonsilar hyperemia was found, small point-like enanthema on soft palate. In skin folds, lateral surface of the trunk and neck - small maculous rash. Increased front-cervical lymphatic nodes are palpated.
What is the probable diagnosis?
A. Rubella
B. Chickenpox
C. Pseudotuberculosis
D. Hemorrhagic purpura
E. Scarlet fever
2. The child, 9 years old, is ill for 6 days. He complains of increasing body temperature to 38 °C, pain during swallowing, small maculous rash on neck, upper part of the trunk, skin folds. Objectively: pharyngeal and tonsilar hyperemia was found, small point-like enanthema on soft palate. What laboratory investigation will confirm the Scarlet fever?
A. Thick smear of the blood
B. Smears from the pharynx on viral parts
C. Blood culture
D. The agglutination reaction to reveal the antigen in material
E. The swab from nose and pharynx on bacillus Lefleri
3. The girl, 7 years old, complains of pain in the throat, increasing of the body temperature to febrile, headache, and sickness. During objective examination: bright point-like rash on flexible
surfaces of the limbs, lateral surface of the trunk, internal and back surfaces of the thigh, increased front-cervical lymphatic nodes, "blazing pharynx". The scarlet fever was diagnosed. What bacteria cause this disease?
A. Staphylococci
B. Betha-haemolytic streptococci
C. Escherichia coli
D. Bacillus cereus
E. Gram-positive diplococci
Real situation to be solved:
1.A girl, 6 years old complains of sore throat, fever 39.2 °C, rashes on the skin. She is ill for 2 days. Rashes have appeared today. During examination of the patient pharyngeal and tonsilar erythema, purulent tonsilar exudates, enlargement of anterior cervical lymph nodes, erythema of the soft palate were found. Rashes as red tiny papules on the trunk and extremities, intensified in skin folds, the face is flushing with circumoral pallor.
1. Name diagnosis.
2. Account a dose of penicillin G for this patient.
2. A mother has addressed to physician with the girl, 5 years old. The mother complains of raised temperature in child and multiple vomiting. The disease has begun suddenly. During examination: dry lips, sclera inj ection, hyperemia of the pharynx, the tongue is covered by white "coat", small point-like rash on neck, upper part of the trunk, in skin folds. The pulse is small, heart tones are muffled.
1. What form of the scarlet fever has this child?
2. What clinical signs will prove this diagnosis?
Answer for the self-control:
Test: l.B;2.B;3.E;4.E;5.D;6.D;7.E;8.E;9.A; 10.D.
Step: l.E;2.D;3.B.
Real life situation 1:
1. Scarlet fever
2. 100000 IU x 22kg=2,200,000 IU per day. 2,200,000:4=550,000 IU four times daily.
Real life situation 2:
1. The severe toxic form.
2. Multiple vomiting. The pulse is small, heart tones are muffled.
Aids and material tools: Charts "Scarlet fever", photo, video.
Result level Students must know:
1. Etiology, epidemiology and pathogenesis of scarlet fever.
2. Clinical diagnostic features of scarlet fever.
3. Laboratory examination of patient with scarlet fever.
4. Differential diagnosis of scarlet fever.
5. Main treatment of scarlet fever.
6. Prophylaxis of scarlet fever.
Students should be able to:
1. Separate anamnesis data, which told us about scarlet fever.
2. Find diagnostic clinical criteria of scarlet fever during examination of the patient.
3. To perform differential diagnosis among diseases, which have the similar clinical features.
4. To learn the main tendentions of scarlet fever treatment.
5. To perform prophylaxis of scarlet fever.
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