Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT
--Otitis Media:
Classification, Rx and Complications
--Pediatric ENT:
1. When to Refer for Tubes
2. Laryngeal Abnormalities
--The Treatment of Otorrhea
--Eye Problems of Children
--Allergic Rhinitis
--Sinusitis vs. Purulent Rhinitis vs. URI
--“Treatment” of the Common Cold
--Frequently Used OTC Medications for the Common Cold
--Facial Nerve Palsy in Pediatrics
--Strep Throat

Other Streptococcal Infections in Children

1. Impetigo: Must cover strep as well as staph aureus when treating impetigo.

2. Ecthyma: Resembles impetigo, but evolves into a deeper more chronic infection.  Initial lesion is a vesicle, which then ulcerates into a dry heaped-up crust. Can progress to ecthyma gangrenosa: a necrotic ulcer.

3. Erysipelas: A well demarcated acute infection of the skin involving the face and extremities. Skin is erythematous and indurated; advancing margins are raised and firm.  Usually associated with fever, vomiting, and irritability.

4. Perianal cellulitis: Symptoms are of local itching, pain, blood in stools, erythema and proctitis.  Can often occur with concomitant strep pharyngitis.

5. Blistering distal dactylitis: A beta hemolytic strep infection of the fingertips. Treatment includes an I and D.

6. Bacteremia: Can follow localized cutaneous or respiratory infections.  Can be seen in children with underlying immune problems.

7. Pyogenic Arthritis and pneumonitis - Less common

Invasive Disease: Mortality in children: 5-10%; adults: 40-50%

1. Necrotizing Fasciitis: Also requires aggressive surgical debridement; starts with skin erythema and edema with pain out of proportion to physical findings.  Clindamycin should be included in the treatment - much more effective than penicillin. (reduces toxin effect)

2. Toxic Shock Syndrome: Cutaneous focus (Ecthyma) and soft tissue focus which are accompanied by necrotizing or bullous soft tissue changes.  Characteristic feature is one of rapidly progressing multi-organ failure with fever, rash, desquamation, and hypotension.  A high proportion of the strains of Streptococcus pyogenes is serotype M-1.  Cause may be erythrogenic toxin B. (rather than A or C).  This syndrome has been linked with the appearance of a new dominant strep serotype.  If there is low immunity to this new type, there will be an increase in the number of invasive cases.  It is the toxin from M protein that causes this (NEJM 1996;335:589).  Treatment should include early radical operative debridement? hyperbaric O2.

Diagnostic Criteria of TSS:

Definite case: Isolation of Grp A Strep from normally sterile area - such as blood (75%);

Probable case: Isolation from nonsterile body site plus one clinical sign

Clinical signs: Two or more of the following: hypotension; liver involvement; adult-type RDS; renal impairment, coagulopathy, generalized macular rash; soft tissue necrosis.

Other Streptococci Causing Disease:

• C: pharyngitis
• B: neonatal sepsis and meningitis
• D: UTI (resistant to penicillin, but sensitive to ampicillin)
• G: endovascular infection, endocarditis, and septic arthritis
• Viridans: Bacterial Endocarditis; Alpha hemolytic strains: also resistant to penicillin and sensitive to ampicillin.

Reviewed 1/02

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004