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

[Painter1]

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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[southerndoc]

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

 

[NateintheED]

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.

 

[southerndoc]

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.

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.

 

[Stitch]

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.

 

[corpsmanUP]

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.

 

[Rendar5]

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.

Well, tell him to come online and explain it or is it in his book?

 

[J-Rad]

http://www.epmonthly.com/index.php?option=com_content&task=view&id=451&Itemid=73

Thanks for dropping that name. I Googled (hadn't heard of him) and came accross this recent article.
It's particularly interesting since where I'm training we've been involved in a small cluster of RF (as consulting peds cardiologists). I think the most recent one had been treated for pharyngitis with abx.

 

[Jeff698]

Well, tell him to come online and explain it or is it in his book?

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

 

[leviathan]

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?

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?

 

[TysonCook]

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

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.

 

[Stitch]

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?

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.

 

[DrQuinn]

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

 

[Stitch]

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

Q

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 . Not a good reason to do it of course, and I have no trouble sending them back to their PCP.

 

[Jeff698]

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.

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

 

[kungfufishing]

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

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.

 

[Jeff698]

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.

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