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Week 4: Dermatology Discussion Question – Scarlet Fever
A 10-year-old Asian patient presents with an erythematous maculopapular rash, conjunctivitis, a mild fever of 102.1 and a strawberry tongue. The rash started 4 days ago.
Q: How are you going to evaluate this patient?
Evaluation of this pediatric patient will begin with a thorough history-taking with the patient and parent(s) and then a physical assessment. The questionnaire will be in the form of OLDCARTS. Inquiries will be made into any recent illnesses or being in proximity to others who have been sick. Other questions will include the presence of a sore throat.
Physical assessments will involve the head, eyes, ears, nose, and throat (HEENT) system and the integumentary system. Working from head-to-toe mythology, visual inspection of the head would be first, noting abnormalities of redness, drainage (rheum, otorrhea, or rhinorrhea), erythema, and edema. Focusing on potential causation of the fever and rash, an otoscopy of the ears, inspection of the conjunctiva, nares, and oropharynx would follow (Harberger & Graber, 2023). A visual assessment and palpation of the neck to evaluate for the presence of any tonsillar, pharyngeal, or lymphatic may be involved (Harberger & Graber, 2023). Furthermore, the inspection of the different regions where the rash is located.
To eliminate differential diagnosis, taking a history of the present illness and physical examination are not enough. There are diagnostic tests to consider ordering that would provide valuable information for a diagnosis, such as a throat swab of a bacterial culture or rapid antigen detection test (RADT) for group A streptococcus (GAS), which is the pathogen that typically causes pharyngitis (Luo et al., 2019). The RADT test is a quick and easy diagnostic tool with exceptionally low false positive results (Luo et al., 2019).
Q: What is the differential diagnosis for this patient?
Differential diagnosis #1) Complications of group A streptococcus pharyngitis (GAS) (ICD-10 Code B95.0) is mostly the diagnosis due to the clinical presentations of erythematous maculopapular rash, conjunctivitis, a mild fever of 102.1, and a strawberry tongue. GAS is the most common bacterial pathogen that causes pharyngitis (Luo et al., 2019). The rash described is likely a complication of the toxins produced by GAS, which are called streptococcal pyrogenic exotoxins or simply superantigens (Hurst et al., 2021). The incidence of GAS pharyngitis is highest among the pediatric population (Luo et al., 2019). Furthermore, this complication from GAS pharyngitis more commonly occurs in patients between the ages of 5 to 15 (Hurst et al., 2021). More than 83 percent of the cases of GAS pharyngitis are diagnosed within primary care settings (Luo et al., 2019).
Differential diagnosis #2) Kawasaki disease (ICD-10 Code M30.3) is commonly described as having these distinctive characteristics “persistent fever, bilateral non-purulent conjunctivitis, diffuse oral fissures, a distinctive skin rash, edema of the hands and feet, as well as lymphadenopathy of the neck” (para. 2). The diagnosis of Kawasaki is distinctive and requires symptoms of fever of above 38 °C for 5 days or greater and at least 4 of the 5 following criteria: 1) bilateral conjunctival without rheum, 2) oral mucosa changes (“fissured lips, strawberry tongue, or a red pharynx”), 3) hands, palms, feet, and soles that are erythema, edematous, or skin peeling, 4) diverse rash, and 5) lymphadenopathy with a diameter of 1.5 cm or greater (Hurst et al., 2021, para. 3). This diagnosis is least likely due to the duration of the fever being only four days and the absence of the required four criteria.
Differential diagnosis #3) Measles (ICD-10 Code B05.9) is characterized by high-grade fever of 40 °C or greater, coughing, erythematous and edematous oral mucosa, and conjunctivitis (Misin et al., 2020). Instead of strawberry tongue, measles is more commonly associated with Koplik spots that occur two to three days prior to onset of a rash (Misin et al., 2020). Koplik spots are described as “bluish-white lesions, slightly raised by 2–3 mm, on a reddened base and are identifiable on the oral mucosa at the level of the first molar but may also occur at the level of the soft palate” (Misin et al., 2020, para. 17). Then the rash may present one to two days afterward, initially on the face and to the palms (Misin et al., 2020). Due to this typical clinical presentation of measles, this diagnosis is unlikely.
Q: Describe your treatment plan based on current guidelines.
The Centers for Disease Control and Prevention (CDC) cited the current recommended treatment plan for GAS pharyngitis in accordance with the clinical practice guidelines suggested by Infectious Diseases Society of America (CDC, 2022). The recommended treatment for complicated GAS pharyngitis includes a wide option range of oral antibiotics and one intramuscular (IM) antibiotic option (CDC, 2022). For this 10-year-old patient without a penicillin allergy, the recommended treatments are 10-day course of:
1) Penicillin V 250 mg PO BID or TID or
2) Amoxicillin 50 mg per kg (mg/kg) PO daily with a maximum dose of 1000 mg daily or splitting it to 25 mg/kg PO BID (CDC, 2022).
3) The other option is the one-time IM injection of benzathine penicillin G of 600,000 units for patients who are less than 27 kg or 1,200,000 units for patients who are over 27 kg (CDC, 2022).
For patients with a penicillin allergy, the suggested oral treatment includes 10-day course of:
1) Cephalexin 20 mg per kg per dose (mg/kg/dose) BID with a maximum dose of 500 mg/dose,
2) Cefadroxil 30 mg/kg daily with a maximum dose of 1000 mg,
3) Clindamycin 7 mg/kg/dose TID with a maximum 300 mg/dose, or
4) Clarithromycin 7.5 mg/kg/dose BID with a maximum 250 mg/dose (CDC, 2022).
The five-day course option for patients with penicillin allergy is to take azithromycin 12 mg/kg daily with the maximum daily allowance of 500 mg (CDC, 2022).
References
Centers for Disease Control and Prevention. (2022, June 27). Scarlet fever. https://www.cdc.gov/groupastrep/diseases-hcp/scarlet-fever.html
Harberger, S., & Graber, M. (2023). Bacterial pharyngitis. In: StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559007/
Ho-Chang, K. (2023). Diagnosis, progress, and treatment update of Kawasaki disease. International Journal of Molecular Sciences, 24(18), Article 13948. https://doi.org/0.3390/ijms241813948
Hurst, J. R., Brouwer, S., Walker, M. J., & McCormick, J. K. (2021). Streptococcal superantigens and the return of scarlet fever. PLOS Pathogens, 17(12), Article e1010097. https://doi.org/10.1371/journal.ppat.1010097
Luo, R., Sickler, J., Vahidnia, F., Lee, Y. C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of group a streptococcal pharyngitis in the United States, 2011–2015. BMC Infectious Diseases, 19, Article 193. https://doi.org/10.1186/s12879-019-3835-4
Misin, A., Antonello, R. M., Di Bella, S., Campisciano, G., Zanotta, N., Giacobbe, D. R., Comar, M., & Luzzati, R. (2020). Measles: An overview of a re-emerging disease in children and immunocompromised patients. Microorganisms, 8(2), 276. https://doi.org/10.3390/microorganisms8020276
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