CASE HISTORY• S.K. , 6 yr old boyPC Rash + Fever
HPC1st day: rash started in peri-oral area 4/7 days ago;-Itchy-Blanching-No apparent triggers reported by parents-During the following 24 hours rash spread to the cheeks , UL and LL , chest , back and abdomen.2nd day: associated fever and swelling on hands with rash. GP prescribed-Calamine lotion: pruritus- Piriton: chlorphenamine.3rd day: symptoms worsened, + Vomiting +Diarrhoea.- Given paracetamol , PO and penicillin V, PO
HPC4th day: continuing vomiting +Diarrhoea.- The swelling in the hands extended progressively, with added discomfort and pain on walking and mobility of 4 limbs.-Fever did not improve. TRIAGE VITALS-He was brought in to the hospital for a second time: Temp: 38 C BP: 130/90 RR: 28 O2: 100%
HPC Any thoughts??? Any questions ??..No coryza symptomsNo dysuriaImmunisation up to dateNo foreign travel / visitorsNo family member with same symptoms
PMHPregnancy : normal , no drugs taken.Perinatal: normal, no complications.Delivery: no complications.Postnatal: no complications.Infancy: repetitive upper respiratory tract infections.Development: Normal development. Walked when he was able to stand with help at 1 yr , able to walk at 1 , 5/12yrsImmunizations: up to date.Surgical Hx: Orchidopexia , due to undescended testis at 1 yrMedical Hx: nothing reported by parentsMed: nil regAllergies: none known.
FH-2 Older sisters healthy.-No one in the family with similar symptoms.-Father: cardiac problems and high cholesterol on father family line.-Mother: (-)SH-He currently attends school on yr 1-No problems with school, no problems socialising “he’s actually a very popular kid”-No problems at home reported.-No recent travel-No pets
S/R-General: looking poorly for last 4 days, feeding ok and drinking ok , despite vomiting.-ENT: dry cough before the episode of rash + fever , swollen tonsils, difficulties with swallowing.-GI: diarrhoea-RS: no asthma , no SOB, no palpitations-CVS: (-)-GUS: urine colour changes-NS: (-)-MSS: pain in hand bilaterally ,-SKIN: raised skin temperature + swelling, itchy maculopapular rash.
O/E-General: alert , responsive cooperative child to examination38 C-RS: (-)-CVS: (-) no cyanosis, no clubbing, no SOB, no murmurs.-ENT: inflamed red throat, red swollen tongue, no palate erythema, ears: L=clear R= waspy , tonsils grade 2-3-Eyes: no conjunctivitis-NS: (-)-MSS: bilateral palmar and plantar erythema, bilateral swelling of both UL & LL, non pitting oedema on both LL and UL, pulses present in both UL and LL.-SKIN: generalised warm skin temperature + swelling, maculopapular rash on the back , patchy over the thighs.
DiagnosisKey points to reach diagnosis: fever + rash-Decide which type of rash is: macular, maculopapular, vesicular purpuric.-Determine if the child is ill.-Beware of diagnosis Measles or Rubella without serological confirmation.-If the rash is petechial or purpuric child unwell ,treat with penicillin IM and admit for investigation.
Scarlet Fever- Rash that may occur with Streptoccocal pharyngitis.- Caused by group A haemolytic streptoccoci.- Treated with Antibiotic.
Scarlet FeverCLINICAL FEATURES- 2-4 incubation period- Headache and tonsillitis appear after- Rash develops within 2 hours- Spreads rapidly over trunk and neck- With increased density in the neck, axillae and groins.
Scarlet Fever. CLINICAL FEATURES - A fine punctuate erythematous appearance - A “sand papery” feel. - And blanching on pressure. - Tongue white first then “red strawberry” - Rash lasts about 6 days followed by peeling
Scarlet Fever. INVESTIGATIONS - Throat swab mat show group A streptococcus - Antistreptolysin ( ASO ) titre is high.
Scarlet Fever. MANAGEMENT - 10- day course of penicillin V or erythromycin - Isolation: children should be isolated until 24th after the start of antiibiotics - Antibiotic prevents other children from being infected and reduce lenght of illness. - Should be started within 9 days of acute illness. - Follow updated hospital guidelines if at all any.
References Rudolf M, Lee T, Levene M. Paediatrics and Child Health. Wiley Blackwell, 2001; 3rd ed. Lissauer T, Clayden G. Illustrated textbook of Paediatrics. UK: Mosby Elsevier, 2007; 3rd ed. Tasker R, McClure R, Acerini C. Oxford handbook of Paediatrics. Oxford: Oxford University press, 2008.