Scarlet fever ( infectious diseases )

is an upper respiratory tract bacterial infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin) -producing GAS in individuals who do not have antitoxin antibodies In the past.
scarlet fever was thought to reflect infection of an individual lacking toxin-specific immunity with a toxin-producing strain of GAS.

Subsequent studies have suggested that development of the scarlet fever rash may reflect a hypersensitivity reaction requiring prior exposure to the toxin.

1. Scarlet fever DONE BY : MUSTAFA KHALIL IBRAHIM T bilisi S tate M edical U niversity 6 th Year, 1 st Semester, 1 st Group pediatric infectious diseases

2. is an upper respiratory tract bacterial infection associated with a characteristic rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin) -producing GAS in individuals who do not have antitoxin antibodies In the past. scarlet fever was thought to reflect infection of an individual lacking toxin-specific immunity with a toxin-producing strain of GAS. Subsequent studies have suggested that development of the scarlet fever rash may reflect a hypersensitivity reaction requiring prior exposure to the toxin . DEFINITION called : Scarlatina

3. EPIDEMIOLOGY Scarlet fever occurs mostly in children aged 4-8 years. Scarlet fever generally has a 3-6 day incubation period (1-7 days). Common in late winter and early spring. By 10 years old, up to 80% of children have developed lifelong protective antibodies against streptococcal toxins, whilst children younger than 2 years still have acquired maternal anti-exotoxin antibodies. Males and females are affected equally.

4. TRANSMISSION Group A streptococcal infections that cause scarlet fever are contagious . Streptococcal bacteria can spread from person to person by breathing in airborne droplets from an infected person's coughing or sneezing . Bacteria can also be passed by touching the infected skin of someone with a streptococcal skin infection, or by sharing contaminated clothes, towels or bed linen. Scarlet fever can also be spread by infected individuals who are carriers of streptococcal bacteria but do not show any symptoms. To get scarlet fever you must have recently had a sore throat (strep throat) or school sores (impetigo) caused by certain strains of the group A streptococcus Up to 15-20% of school-age children are thought to be asymptomatic carriers.

5. Group A beta- haemolytic streptococcus bacteria. Streptococci are gram-positive, spherical to ovoid bacteria. Most streptococci that cause human infections are facultative anaerobes. The rash arises from the effects of one of several toxins, currently designated streptococcal pyrogenic exotoxins and previously known as erythrogenic or scarlet fever toxins. ETIOLOGY

6. Adhere to epithelial cells in pharynx via F Protein. Extracellular Products: Streptolysins S and - toxins that damage cell membranes and account for the hemolysis produced by the organisms Streptokinase DNAases SpyCEP - a serine protease that cleaves and inactivates the chemo-attractant cytokine interleukin 8, thereby inhibiting neutrophil recruitment to the site of infection Several pyrogenic exotoxins – produce characteristic rash and fever. PATHOGENESIS

7. Incubation period is usually 3-6 days (1-7 days). with approximately 3 days duration: fever, 39°-40°C headache dysphagia, vomiting, . tachycardia. In infants and young children the symptoms can be also accompanied by seizures . Exanthem The erythema abates in 7-9 days. SIGNS AND SYMPTOMS

8. Filatov’s mask - circumoral pallor

9. Pastia’s lines - accentuation of the rash in skinfolds .

10. GENERALIZED RASH- approx . 24hrs after onset. Begins on trunk and spreads to extremities. Minute papules ， give a characteristic "sandpaper" feel to the skin. Blanch when pressure is applied.

11. DESQUAMATION PERIOD starts after 7-14 days of illness It often begins around the neck and spreads over the trunk and extremities. It is a diffuse, finely papular, erythematous eruption producing a bright red discoloration of the skin, which blanches on pressure .

12. The exudative pharyngitis typical of scarlet fever. Although the tongue is somewhat out of focus, the whitish coating observed early in scarlet fever is visible

13. Clinical diagnosis supported by lab investigations. Throat or nasal culture or rapid streptococcal test. Serologic : positive for antistreptolysin -O titers and Anti- dexoyribonuclease B. CBC : leukocytosis, neutrophilia , high ESR, and C-Reactive protein. DIAGNOSIS

14. Physical examination

15. Measles Rubella Drug induced exanthema Erythema Infectiosum (Parvovirus B19) EBV Roseola Infantum DIFFERENTIAL DIAGNOSIS

16. Antibiotics are used to kill the bacteria that causes the throat infection. This is crucial to prevent rheumatic fever, a serious complication of strep throat and scarlet fever. TREATMENT

17. Rheumatic fever Otitis media Pneumonia Septicaemia Glomerulonephritis Osteomyelitis COMPLICATIONS

18. Complications are rare with the right treatment, but can include: Acute rheumatic fever Bone or joint problems Ear infection Inflammation of a gland (adenitis) or abscess Kidney damage Liver damage Meningitis Pneumonia Sinusitis

19. With proper antibiotic treatment, the symptoms of scarlet fever should get better quickly. However, the rash can last up to 2-3 weeks before it fully goes away. EXPECTATIONS!!

20. Case study

21. Chief Complaint — Sore throat and rash

22. history OF PRESENT ILLNESS — Sophie* aged 19 had experienced a ten day history of a sore throat and an eight-day history of a rash on her legs. She had been to see her GP who thought it likely strep throat. A throat swab was taken and she was commenced on a ten-day course of oral penicillin and analgesia. Two days later Sophie had felt worse and had now developed a fever. Her rash had now spread to her arms and a little on her trunk . She attended an after- hours acute doctor . Her throat swab had come back as negative for Strep . This GP thought her symptoms were related to an allergy . The penicillin was stopped and Sophie was started on loratadine 10mg daily. Two days later re-presented to Student Health. She still felt 'unwell'. Sore throat much less but skin 'aching ' .

23. Su b je c t i v e — Medications – Jadelle implant. Loratadine 10mg od, ibuprofen 200mg 2 tabs qid prn, paracetamol 500mg 2 tabs qid prn . NKA — Immunisations – fully-immunised as a child. Received Menz-B and Gardisil at school. Last ADT age 11 . — Medical hx – EBV on past serology. Positive strep A last year. Eczema as a child . — F am i l y h x – p a ren t s an d t wo b r o t he r s a l i v e an d we l l . M at e r n al grandmother breast cancer. Nil diabetes or IHD. — So c i al h x – f i r s t y ear at U n i v e r s i t y an d f i r s t y ear a w a y f r o m h o m e . L i v es in a Hall of Residence. Studying commerce, hopes to become an accountant. Is fairly active. Goes to the gym 3x per week and walks 'everywhere'

24. Review of Systems — General – feeling feverish, tired and generally unwell — HEENT – nil headaches, blurred vision, sore ears, facial swelling. Sore throat and 'snuffly' nose. Nil neck pain or stiffness — Respiratory/Cardiac – nil wheeze, SOB or increased work of breathing. Occasional dry cough at night. Nil chest pain, palpitations or dizziness — Gastro – eating and drinking normally. Nil vomiting, nausea or diarrhoea — Integumentary – hot, itchy and 'aching '. Eczema as a child but nil other history of rashes or allergies

25. Objective — General – looks miserable but alert. Slim build, appears stated age. Good eye contact, appropriate speech. Dressed appropriately for season (Winter), clean and tidy with hair tied up. — Obs - Temp 38.5, HR 108 reg, Resps 16, BP – 110/76 — HEENT plus neck – Throat red, tonsils slightly enlarged, slight exudate R>L. Nil Kopliks, tongue red with some white distally. Nil lymphodenopathy, non-tender. Neck supple — Respiratory/Cardiac – good equal air entry, vesicular, nil crepes or wheeze — G as t r o – a bd o men s o ft , n o n -t en d e r . N il g u a r d i n g o r t en d e r n es s . N il masses — Integumentary – widespread maculopatchy rash all over body, confluent around knees and shoulders, face and neck spared. Nil papules, blanches easily. Feels hot to touch Demonstrates competency 2.1

26. Objective continued… Photo Credit Dermnet NZ (2012)

27. Objective continued… Photo credit Dermnet (2012)

28. A ss e s s men t — Possible Scarlet Fever — Possible rash related to strep throat — Possible other viral exanthem including measles, rubella and other non- specific viruses — Possible Epstein-Barr Virus  Other rashes such as erythema multiforme, exfoliative dermatitis, pityriasis rosea, drug rashes, severe sunburn, plant allergies, toxic epidermal necrolysis and staphyloccoccal scalded skin syndrome — Possible toxic shock syndrome though unlikely due to absence of high fever (>38.9), hypotension, vaginal symptoms, and GI .  Possible Kawasaki disease Demonstrates competencies 1.1, 2.1, 2.2, 2.4

29. P l an RX - re-start antibiotics - Phenoxymethylpenicillin 500mg bd for ten days * DX – throat swab, bloods (CRP, FBC and ASO titre ED – rest, fluids, advise red flags for urgent review F/U – review in two days with results unless any deterioration Demonstrates competencies 1.1, 2.1, 2.4 & Domain Four

30. R e s u l t s — Haemoglobin : 136 g/L ( 120 - 155 ) PCV : 0.40 ( 0.35 - 0.46 ) — MCV : 92 fL ( 81 - 98 ) MCH : 31.3 pg ( 27.0 - 33.0 ) Platelets : 292 x 10e9/L ( 150 - 430 ) WBC : 13.8 x 10e9/L ( 4.0 - 11.0 ) H Neutrophils: 10.6 x 10e9/L ( 1.90 - 7.50 ) H Lymphocytes: 1.8 x 10e9/L ( 1.00 - 4.00 ) Monocytes: 0.8 x 10e9/L ( 0.20 - 1.00 ) E o s i n o p h i l s : 0.6 x 10e9/L ( < 0.6 ) HH Basophils: 0.0 x 10e9/L ( < 0.3 ) — Demonstrates competency 2.1

31. Results continued… — A . S . O . T : 1022 IU/mL ( < 240 ) H — CR P : 41 mg/L ( < 5 ) H Demonstrates competency 2.1

32. Follow-up Appointment — Sophie feeling quite a bit better. Rash starting to fade and a lot less itchy — Throat swab positive for Streptoccoci A — Bloods showed an elevated CRP, neutrophilia, eosinophilia and an elevated WBC count. Also her ASOT was nearly four times the normal — Highly likely Scarlet Fever Demonstrates competencies 2.2, 2.3, 2.5, 3.1

33. Decision Making — Diagnosis of scarlet fever — Clinical findings — Throat culture for group A strep — Blood test — The blood test shows neutrophilia and increased eosinophils, elevated C-reactive protein (CRP) and elevation of antistreptolysin O titer. — Blood culture not used as is rarely positive but the streptococci can usually be demonstrated in throat culture Demonstrates competencies 1.1, 2.1, 2.2, 2.4

34. Nelson Textbook of Pediatrics, 19th Editon - Kliegman . https:// www.cdc.gov/groupastrep/diseases-public/scarlet-fever.html —Best Practice (2011). Rheumatic fever in Maori: what can we do better? Retrieved from http://www.bpac.org.nz/magazine/2011/august/rheumatic.asp on 29/9/12 — Bickley , L.S. (2007). Bates' guide to physical examination and history taking (9th Ed). Philadelphia, USA: Lippincott Williams & Wilkins — Dermnet NZ (2012). Scarlet Fever. Retrieved from http ://www.dermnetnz.org/bacterial/scarlet-fever.html on 27/9/12 — Ferri , F.F. (2007). Ferri's clinical advisor: instant diagnosis and treatment. Philadelphia, USA: Elsevier Inc . — Goolsby , M.J & Grubbs, L. (2011). Advanced assessment: Interpreting findings and formulating differential diagnosis. Philadelphia; F.A. Davis Company REFERENCES