thinkertdm Posted January 27, 2018 Share Posted January 27, 2018 Here's a scenario: 4yo with a "few day" history of rhinorrhea, nasal congestion, intermittent cough developed a fever of 103F overnight and sore throat. Not eating due to pain. Moderate pain in left ear. No abdominal pain. No obvious rashes per father. Prior history of tonsillectomy. Physical exam showed a moderately sick looking kid, but nontoxic and in no acute distress. Left ear was retracted and very erythematous. Right ear somewhat bulging, but nonerythematous. Difficult to visualize throat due to compliance, but no exudates noted, and no tonsils. I did note two vesicles (not ulcers), one on his left anterior tonsillar pillar and one on his soft upper palate. Moderate bilateral lymphadenopathy in the anterior cervical chain. Febrile with a temp of 101F, father treated two hours earlier with tylenol. Was swabbed per clinic policy and was positive for group A strep. A single 2mm erythematous papular lesion noted on his left 2nd phalange at the PIP joint. They do not recall it being there. I figure either hand, foot, mouth or herpangina with strep colonization as well as left acute otitis media. I did treat, wrote my thoughts in the note and sent to the PCP. He no doubt did not read it. I did discuss with the father about colonization vs infection, he seemed to understand, but who knows. I wrote it down for him. I chose omnicef because I was concerned about a possible antibiotic associate rash with HFM and amoxicillin. Link to comment Share on other sites More sharing options...
d2305 Posted January 27, 2018 Share Posted January 27, 2018 NONSUPPURATIVE COMPLICATIONS Acute rheumatic fever Poststreptococcal reactive arthritis Scarlet fever Streptococcal toxic shock syndrome Acute glomerulonephritis PANDAS syndrome SUPPURATIVE COMPLICATIONS Tonsillopharyngeal cellulitis or abscess Otitis media Sinusitis Skin and soft tissue infections I treat. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted January 27, 2018 Share Posted January 27, 2018 2 hours ago, d2305 said: NONSUPPURATIVE COMPLICATIONS Acute rheumatic fever Poststreptococcal reactive arthritis Scarlet fever Streptococcal toxic shock syndrome Acute glomerulonephritis PANDAS syndrome SUPPURATIVE COMPLICATIONS Tonsillopharyngeal cellulitis or abscess Otitis media Sinusitis Skin and soft tissue infections I treat. I have a question regarding the "complication" of OM. If you have a functional eustachian tube how are you going to maintain OM, especially with an effusion? Here's just an off the wall comment. If folks have tonsils and have tonsillar hypertrophy, can we not reasonably assume that "the other guys" known as adenoids are probably inflamed and hypertrophied as well? If so, they what will their hypertrophied state obstruct? The eustachian tube(s). Anyone else note that during non-snot season the sore throats with subsequent tonsillar hypertrophy can usually be identified based on which ear is concurrently bothering the patient? Getting back to peds OM, I've got a staff member whose kid is on their third set of tubes and still gets erythematous, bulging TMs. So either the tube is occluded (they're NEVER positioned where you can see down the thing) or it is not in the TM as originally placed. All this being said, why don't we approach OM from the other direction and use removable stents for the eustachian tubes (ENT now doing this for adult chronic ETD thanks to their cardiology brethren) that can be removed just as the ureteral stents can be for stones? When we use the recommended wait/observe policy of AAP for OM in essence that's what we're doing is awaiting the ET to reopen and "flush" the middle/inner ear. I don't think I've ever found a PANDA in the throat though the kids will tell you that I find all sorts of other wild beasts. Link to comment Share on other sites More sharing options...
sk732 Posted January 27, 2018 Share Posted January 27, 2018 I guess this goes back to what I said about things being actually caused by non treatment vs post treatment autoimmune reaction to the ASO - the non-suppurative things might actually be results of autoimmune reaction, whether treated or not. PSGN I've seen in treated people; can't say I've ever seen PANDAS outside of a zoo or Nat Geo. Sure, the odd person gets OM - they might get it anyway with treatment because their tonsils haven't shrunk yet or nodes haven't gone down. Sinusitis??!! They likely came in with a viral URTI/pharyngitis and colonizing. Scarlet Fever - all cases I've come across over the years haven't been secondary issues - they started out as acute strep tonsillitis with scarlatina within <24hrs of onset of the sore throat/fever if not concomitantly...in fact, I've diagnosed a number of cases in the past couple months after not having seen any for a couple years. PTA - since they're usually mixed bags, of strep and other things, I can buy in, though there are other things that can cause them too. This is the reason some of us think we may need to revisit why we're treating strep throat...how much and what quality of evidence is there or are we just doing this because we learned it in school (much like I do, lol). SK Link to comment Share on other sites More sharing options...
d2305 Posted January 28, 2018 Share Posted January 28, 2018 If one does this job long enough, one sees some rare complications. I wish the Pts with PETs would f/u with ent. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 2, 2018 Share Posted February 2, 2018 Scott, any follow up from your higher ups, or at least those who are still speaking to you? ;-) Link to comment Share on other sites More sharing options...
Cideous Posted February 4, 2018 Share Posted February 4, 2018 Does anyone give the long acting Amoxil for strep? Link to comment Share on other sites More sharing options...
Miaow Posted February 4, 2018 Share Posted February 4, 2018 On 1/21/2018 at 8:49 PM, sk732 said: Correct - if you're getting a ZPack from me, you've got chlamydia...just out of spite, lol. :-D SK I would contend that spite gets you the 1 gram powder pack that is mixed with water and choked down while desperately trying not to vomit. Link to comment Share on other sites More sharing options...
sk732 Posted February 4, 2018 Share Posted February 4, 2018 I would contend that spite gets you the 1 gram powder pack that is mixed with water and choked down while desperately trying not to vomit.Or 1 gram ceftriaxone in the bum without lidocaine...SK Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Miaow Posted February 4, 2018 Share Posted February 4, 2018 13 minutes ago, sk732 said: Or 1 gram ceftriaxone in the bum without lidocaine... SK Sent from my iPhone using Tapatalk I had my nurse give me 1 gram of Rocephin without lidocaine once for pyelo ... It literally hurt for days. Link to comment Share on other sites More sharing options...
sk732 Posted February 4, 2018 Share Posted February 4, 2018 I had my nurse give me 1 gram of Rocephin without lidocaine once for pyelo ... It literally hurt for days. First couple times I did it, dropped the dudes...we thought it was injection technique at first until they woke up and told us...SK Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
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