1. PER Case Presentation Presented by R2 柯汶姍 Instructor: Dr. 岑秋良, Dr. 張孟維

2. Identification Name: 楊 × 彬 Gender: Boy Age: 3 y/o 7 m/o Chart No. 10170808

3. Vital sign T/P/R 36.4*C / 97bpm / 26/min E4V5M6 檢傷 : 3 級 主訴 : 右腳腫痛, 由父母親帶入急診

4. Chief complaints Redness, warmth and pain over right thigh was noted since 01/12 evening

5. Present illness This 3y/o 7 m/o boy was well being before. According to his mother ’ s statement, he suffered from redness, local heat, mild swelling, and pain over his right thigh since 1/12 night. The initial presentation was only pain in the evening. There were also papules and itching sensation noted later.

6. No trauma, no wound, no insect biting were noted. No fever, no chills were noticed. No cough, no rhinorrhea. His appetite and activity were good.

7. Past history No known congenital nor developmental diseases No Known food nor drug allergy

8. Physical examination Consciousness: alert, E4V5M6 Neck: supple Throat: enjected, no pus Tonsils: enlarged, no pus coating Chest: bilateral coarse breathing sound Heart: tachycardia, no murmur Abdomen: soft and flat, normal bowel sound, no tenderness Extremities: freely movable, redness with vesicles over Right thigh

14. Impression 1. Right upper and lower leg skin rash 2. Acute pharyngitis r/o right leg cellulitis r/o Scarlet fever

15. Diagnosis and treatment 1. CBC/DC, CRP, BUN/Cr, GOT, Sugar, B/C*II 2. Group A Streptococcus (Throat swab) 3. Vena 15mg iv stat 4. Oxacillin 400mg iv stat and q6h 5. Gentamicin 30mg iv stat and q12h 6. Consult Dermatologist

16. WBC13600RDW14.9 RBC6.17PLT345K Hb11.3Seg53% Hct36.1Band2% MCV58.5Lymph31% MCH18.3Mono8% MCHC31.3Eosino6%

17. Throat swab: Gr. A Streptococcus Ag (+) CRPBUNCrGOT <0.590.225

18. Dermatologist Impression: Eczematous dermatitis r/o contact dermatitis Suggestion: 1. Elomet cream topi use qd 2. Calamine lotion topi prn 3. Cold compression prn

19. Consult Surgeon Impression: Skin erythema Cellulitis or Necrotizing fascitis was not likely Suggestion: 1. Closedly monitor the skin lesion 2. Surgeon follow-up prn

20. Disposition Antibiotics: Oxacillin shift to Augmentin 400mg iv q8h Admission

21. Discussion Scarlet fever is a syndrome characterized by exudative pharyngitis, fever, and scarlatiniform rash. It is caused by an infection with a pyogenic exotoxin-producing group A beta-hemolytic streptococci. Erythrogenic toxins cause the rash of scarlet fever. Scarlet fever predominantly occurs in children aged 5-15 years.

22. during winter and spring in a setting of crowding and close contact The incubation period for scarlet fever ranges from 12 hours to 7 days. In the US: Up to 10% of the population contracts group A streptococcal pharyngitis. Of this group, up to 10% then develop scarlet fever.

23. History The prodrome is characterized by the following findings: Sore throat Headache Vomiting Abdominal pain Fever The rash appears 1-2 days after onset of illness, first on the neck and then extending to the trunk and extremities.

24. Physical The patient usually appears moderately ill. Fever may be present. The patient may have tachycardia. Tonsils: Edematous, erythematous, and covered with a yellow, gray, or white exudate Petechiae on the soft palate Tender anterior cervical lymphadenopathy Flushed face with perioral pallor Scarlatiniform rash

25. coarse sandpaper, and the erythema blanches with pressure. Pruritic, but usually not painful The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This phase begins with flakes peeling from the face. Appearance of the tongue During the first 2 days of the disease ->white strawberry tongue After 2 days -> red strawberry tongue

32. Cellulitis Cellulitis involves the subcutaneous tissue and is caused by S. pyogenes or S. aureus. There is usually a background of chronic edema and stasis dermatitis, and tinea pedis is most common portal of entry associated with leg cellulitis.

33. Reference Skin Microflora and Bacterial Infections of the Skin, Journal of Investigative Dermatology Volume 6 Page 170 - December 2001 Pediatrics, Scarlet fever From e-medicine, Last Updated: October 19, 2005

34. Thanks for your attention!