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Abstract: Most adolescents come to the clinic with fever with rash. The initial judgment involves the differential diagnosis of fever with rash, which requires a judgment of the diseases that may cause it, such as measles, rubella, chickenpox, drug rash, and scarlet fever. For example, in this case, the patient came to the clinic with fever and sore throat with rash for 2 days, and was diagnosed with scarlet fever based on physical examination and test results, and improved after being given antibiotics and other medications. Scarlet fever is a streptococcal infection, and complications may occur if treatment is delayed, so early and clear diagnosis is essential.
[Basic information] Male, 16 years old
Type of disease】Scarlet fever, pneumonia
Hospital】Liaoning Provincial People’s Hospital
Consultation date】April 2019
Treatment plan】Isolation + anti-infection treatment (azithromycin intravenous drip) + immune booster (thin glucose peptide injection) + antimicrobial
【Treatment period】Inpatient treatment for 9 days, outpatient follow-up after 15 days
Effectiveness】The indexes recovered and the disease was cured.
I. Initial consultation
The patient came to the hospital with a complaint of fever, sore throat and rash for 2 days. The patient started to have fever with sore throat 2 days ago, and her body temperature fluctuated around 37.6°C. Within 1 day, a rash appeared, mainly on her head and neck, accompanied by itchy skin. He was found to have a temperature of 37.1℃, a congested pharynx, no enlarged tonsils, a strawberry tongue, a dense corn-like rash on the head, face, neck and trunk, the size of a needle point, some of the rashes were fused, the skin between the rashes was congested, the breath sounds in both lungs were coarse, and a few vesicular sounds could be heard. Blood tests showed a white blood cell count of 14.5×10^9/L and a neutrophil ratio of 87.4%. Lung CT showed a little inflammation in both lungs.
Diagnosis of the type of disease that triggered the symptoms requires differentiation between fever with rash-like illnesses, such as chickenpox, scarlet fever, measles, rubella, and several types of drug rash. In terms of the time of rash onset and rash pattern after fever, we can exclude chickenpox (viral infection, rash emerges within 24 hours, usually through the process of maculopapular rash-papular rash-herpetic rash-crust), measles (viral infection, rash emerges only 3-4 days after fever, rash is maculopapular rash of various sizes), rubella (viral infection, rash emerges within 24 hours, rash pattern is variable), and drug rash (history of drug use). Combining the above with the patient’s fever, pharyngitis, typical scarlet fever-like rash, and blood tests suggesting bacterial infection, the preliminary diagnosis of scarlet fever complicated by pneumonia was made, and the family was informed of the need for isolation and anti-infective treatment, and hospitalization was expected to last more than 1 week.
II. Treatment history
After admission, the patient and his family were anxious about the combination of pneumonia, so they were given some psychological guidance and an explanation of their condition, and their confidence in the treatment was enhanced. The patient was given a complete routine examination and a detailed medical history, and was asked about the topical treatment of levofloxacin and ofloxacin ophthalmic ointment, which had been applied to the patient’s conjunctivitis 10 days earlier, and was not considered to be a drug-induced scarlet fever-like rash because it was a topical drug. The diagnosis of scarlet fever complicated by pneumonia was confirmed by the combination of history and various tests and pathogenic findings. Since the patient had a history of penicillin and cephalosporin allergy, azithromycin intravenous drip was selected. At the same time, in order to recover as soon as possible, the patient was given certain immune enhancers, such as thin glucose peptide injection.
III. Treatment effect
The patient was admitted to the hospital with no further fever, pharyngitis gradually improved, the rash gradually subsided, skin itching was reduced, and the rash had a small amount of desquamation. 1 week later, all the abnormal indexes were improved, the blood routine leukocytes were normal, the eosinophil ratio was 8.5% (elevated), calcitoninogen decreased, and CRP decreased. The patient was discharged from the hospital after 9 days of reexamination, which showed that the patient’s condition was cured. The patient was discharged from the hospital and was instructed to continue oral antimicrobial therapy after discharge and to come back to the hospital for a half month to review pulmonary CT and blood tests.
IV. Notes
We are glad that the patient’s condition was cured after treatment and the indicators recovered, but several points need to be noted.
1. Continue oral antimicrobial therapy after discharge from the hospital, do not discontinue it on your own, and keep your condition under constant observation and review it in half a month.
2. Scarlet fever is not a lifelong immune disease and may lead to reinfection with streptococci, so it is recommended to gradually increase the amount of exercise and develop good fitness habits after recovery to improve the immunity of the body and to maintain a light diet after discharge to help with complete recovery.
The scarlet fever rash is a congestive rash that may be accompanied by itching of the skin. The more severe the rash, the more obvious the flaking will be, and no scars will remain. However, when itching, try not to scratch, once scratched will cause skin bacterial infection, and will also leave a scar.
V. Personal insights
1. Scarlet fever is mainly characterized by fever, pharyngitis, and a typical rash, and is a bacterial infection, so the total white blood cell count can rise up to (10-20) × 10^9/L, and the neutrophils are above 80%. Blood tests for chickenpox, measles, and rubella usually indicate normal or decreased white blood cells, with an increased percentage of monocytes or lymphocytes. A drug-induced rash can appear as a scarlet fever-like rash, which can also be accompanied by itchy skin and elevated blood eosinophils, while scarlet fever can also increase eosinophils after the rash and is sometimes difficult to distinguish from drug rash, so patients need to be asked in detail whether they have a history of drug use to distinguish between drug rash and scarlet fever.
2. It is important to actively seek medical examination to determine which disease is causing the fever rash and to provide symptomatic treatment. If it is caused by scarlet fever, penicillin is preferred, so if you are allergic to penicillin, inform your doctor early and you can apply macrolides such as erythromycin and azithromycin. It is also important to follow the doctor’s prescription for medication to enhance the improvement of the disease after the symptoms are relieved, and to review the disease regularly after discharge to ensure recovery.