kid with sandpaper rash and fever, but no clinical pharyngitis. do u tx?

Discussion in 'Emergency Medicine' started by Painter1, 08.12.09.

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  1. Painter1

    Painter1 Junior Member 7+ Year Member

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    so we all know this 'sandpaper' rash is notriously linked to strep, or more specifically, scarlet fever. but what if you have the classic sandpaper rash and fever but no evidence of pharyngitis? i remember as an intern one of the nurse practioners treated the same case with pcn (e.g., no sorethroat, no neck tenderness, normal pharynx). after some authoritative googling, it appears viral processes can cause a similar rash. would you tx, maybe cx or just have them f/u with pmd?
     
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  3. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor 10+ Year Member

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    Usually, yes. Culture? I almost never do rapid streps or strep cultures. I usually just treat.
     
  4. NateintheED

    NateintheED 5+ Year Member

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    Newly minted attending here, so granted I don't have the experience that many others here do.

    However, in counterpoint to southerndoc's comment (and maybe to stimulate intellectual discussion), I'm not sure I would treat, or even culture. It's well-established that we treat strep throat more to prevent complications thereof (PTA, rheumatic disease, etc) than to really make an impact on the primary disease itself. Antibiotics only decrease symptom duration by less than a day.

    So I think in the absence of clinical pharyngitis (in any way, including complaints of sore throat now resolved), I would think long and hard about giving a medication (PCN) that is one of the most common drug causes of significant allergic reaction.

    Another perspective to think about. Curious what others think.
     
  5. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor 10+ Year Member

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    You're saying that in the presence of a scarlatiliform rash suggesting that the patient has systemic involvement with complications from Strep that you wouldn't treat? This is past the simply Strep throat stage and is starting to get systemic involvement when a rash develops.

    Secondly, remember that Strep infections don't just occur in the throat. People can and do get valvular complications from other Strep infections, including otitis media and even cellulitis. It's not common, but it's not rare either.
     
  6. Stitch

    Stitch Jedi Ninja Wizard SDN Moderator 10+ Year Member

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    I'm primarily peds trained, and I would treat if there's clinical evidence of scarlet fever, for the reasons SouthernDoc mention. However I would do a rapid strep just to see. Usually I give the parents the choice of a one time dose of Pen G or ten days of amox.

    That said, Nate's point is still relevant in terms of strep in general (non systemic). We treat to prevent rheumatic fever, and treatment doesn't prevent post strep glomerulonephritis, so it is worth doing the rapid strep or culture to avoid needless treatment. Children under 3 years of age do not get rheumatic fever, and don't generally ever need to be checked or treated for strep pharyngitis.
     
  7. corpsmanUP

    corpsmanUP Senior Member 7+ Year Member

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    Viral exanthems and the rash of Scarlet Fever are somewhat similar and I personally would not treat without either a history of recent throat pain or a positive strep result.

    Listen to some of the things Dr. David Newman says about strep and you will rethink your entire perspective on treatment in general.
     
  8. Rendar5

    Rendar5 10+ Year Member

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    Well, tell him to come online and explain it:) or is it in his book?
     
  9. J-Rad

    J-Rad Moderator Emeritus 10+ Year Member

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  10. Jeff698

    Jeff698 Chief Resident 10+ Year Member

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    It's in the book. Very interesting. I'd recommend it.

    Unfortunately, it recommends an approach to much of medicine that, while scientifically sound, promise a huge clash with patient expectations that is going to take an awful lot of education to get around.

    When I have double coverage, I can spend time trying to explain some of these issues. Single coverage getting my butt kicked... it doesn't always happen.

    Take care,
    Jeff
     
  11. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus 10+ Year Member

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    We're just starting to cover infectious diseases in school now, but I thought scarlet fever could come from any source of strep infection that is systemically showering out the pyrogenic exotoxins. Thus if there is no pharyngitis, what about a skin infection or otitis media as a source? You won't be at risk for rheumatic fever, but you could still get post-strep glomerulonephritis. Did you check ASO levels?
     
  12. TysonCook

    TysonCook Senior Member 10+ Year Member

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    Agreed with above, its a great read, but I get my butt kicked and unfortunately don't have time to explain microbiology to people with IQ's~70 (on a good day). In a perfect world....no.
     
  13. Stitch

    Stitch Jedi Ninja Wizard SDN Moderator 10+ Year Member

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    Skin infection is definitely worth thinking about. Vaginal and rectal strep can cause problems, so always check there for the beefy redness. OM I don't worry much about. Remember also that treatment with amox or whatever drug you like to use doesn't prevent post strep glomerulonephritis. That complication can happen regardless of treatment.

    I find ASO levels not very useful because they remain elevated for months and there's no way to say that it's related to THIS particular infection or any other in the past 6 months.
     
  14. DrQuinn

    DrQuinn My name is Neo Moderator Emeritus 10+ Year Member

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    I thought the CDC and/or IDSA recommended never treating for strep unless there was laboratory confirmation of GAS?

    Honestly, adults with fever, sore throat, and pharyngitis I tread, but kids I wait for rapid strep antigen....

    Then on the other hand I have given out antibiotics for worse....

    Q
     
  15. Stitch

    Stitch Jedi Ninja Wizard SDN Moderator 10+ Year Member

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    Absolutely true. However there are a boatload of people who still feel they can 'just tell' by looking at a throat. And parents expect you to do the same, just like their PCP :rolleyes:. Not a good reason to do it of course, and I have no trouble sending them back to their PCP.
     
  16. Jeff698

    Jeff698 Chief Resident 10+ Year Member

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    I was listening to Jerry Hoffman's approach to this (ABX "drug seekers") on a recent EMRAPs bouncebacks discussion.

    He tells patients up front that he'll give them the ABX if they want it but he feels the need to explain why he thinks they won't help and may actually hurt.

    I've been using that lately with success (mostly). I had a lady today (sinusitis) who told me I could save my breath because she wanted the ABX no matter what I had to say. Know what I did?

    I saved my breath and wrote the script. Some battles aren't worth fighting.

    On the other hand, I've had very good success with this in avoiding unnecessary CT scans by tossing in that I wouldn't order it for my children.

    These, BTW, were the issues I found needed to be taught in residency.

    Take care,
    Jeff
     
  17. kungfufishing

    kungfufishing Senior Member 7+ Year Member

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    I have also had good results with this approach in the minor peds head trauma crowd. The antibiotic bit seems to be effective 30% of the time, completely unheard 30% (I wonder if I started talking like Charlie Brown's teacher...would she notice?) and 30% overt displeasure.
     
  18. Jeff698

    Jeff698 Chief Resident 10+ Year Member

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    I love it. Blah blah blah blah...

    The next time I launch into that discussion, I'm going to have to try to keep that sound out of my head. Thanks for that. One more thing to try not to think while I'm talking to patients.

    Take care,
    Jeff
     
  19. MGG1848

    MGG1848 Junior Member 10+ Year Member

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    When I am seeing an antiboitic-seeker patient, I have the thought in the back of my mind that I wish certain ABX were available over the counter. Then people could just go see the pharmacist at Walgreens, get a course of antibiotics which does nothing for them except for the placebo effect, and then never go to the ED. OF course this promotes ABX resitance and is probably ethically and morally wrong, but most ER's, PMD's and urgent cares also give it out like candy.
     

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