Scarlatina in children

Scarlet fever is an acute infectious disease with symptoms of general intoxication, sore throat and skin rashes.

Scarlet fever in adults has its own distinctive features.

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Causes of scarlet fever in a child

Scarlet fever is caused by group A streptococci, which produce exotoxins, but the decisive role in the development of scarlet fever belongs to antitoxic immunity. If at the time of infection there is no antitoxic immunity, scarlet fever occurs, in the presence of antitoxic immunity - other forms of the disease: tonsillitis, pharyngitis.

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Pathogenesis

The development of the clinical picture of scarlet fever is associated with the toxic, septic and allergic effects of streptococcus.

• The toxic line is manifested by symptoms of general intoxication: fever, rash, headache, vomiting.
• The septic pathogenesis line is manifested by purulent and necrotic changes at the site of the entry gate and purulent complications.
• The allergic pathogenesis is caused by the sensitization of the body to beta-hemolytic streptococcus.

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Symptoms of scarlet fever in a child

The incubation period of scarlet fever is 2-7 days. Scarlet fever symptoms begin to manifest acutely, with a rise in body temperature, a sore throat when swallowing, headache, and occasional vomiting. A few hours after the onset of the disease, symptoms of scarlet fever appear on the face, trunk, and limbs, with symptoms of a pinkish, pinpoint rash against the background of hyperemic skin. On the face, the rash is located on the cheeks, but the nasolabial triangle is free of rash. The patient's appearance is characteristic: shiny eyes, bright, slightly swollen face, flaming cheeks contrast sharply with the pale nasolabial triangle (Filatov's triangle). In the natural folds of the skin, on the lateral surfaces of the body, the rash is more saturated, especially in the lower abdomen, on the flexor surface of the limbs, in the armpits, elbow folds, and groin area. There are often dark red streaks here as a result of the concentration of the rash and hemorrhagic impregnation (Pastia's sign).

Individual elements of the rash may be miliary, in the form of small, pinhead-sized blisters with transparent or turbid liquid. In more severe cases, the rash may take on a cyanotic hue, and dermographism may be intermittent and weakly expressed. In scarlet fever, capillary permeability is increased, which can be easily detected by applying a tourniquet. The rash usually lasts 3-7 days and, when it disappears, leaves no pigmentation.

After the rash disappears, peeling begins at the end of the first - beginning of the second week of the disease. On the face, the skin peels off in the form of delicate scales. On the trunk, neck, and ears, the peeling is bran-like. It is more abundant after miliary rash. For scarlet fever, lamellar peeling on the palms and soles is typical. It first appears as cracks in the skin at the free edge of the nail and then spreads from the fingertips to the palm and sole. The skin on the extremities peels off in layers. At present, with scarlet fever, peeling is less pronounced.

One of the constant and cardinal symptoms of scarlet fever is changes in the oropharynx. Bright, delimited hyperemia of the tonsils, arches, and uvula does not extend to the mucous membrane of the hard palate. In the first day of the disease, it is often possible to see a punctate enanthem, which can become hemorrhagic. Changes in the oropharynx are so pronounced that they are called, in the words of N. F. Filatov, "a fire in the pharynx", "a flaming sore throat".

Angina in scarlet fever can be catarrhal, follicular, lacunar, but necrotic angina is especially characteristic of this disease. Depending on the severity, necrosis can be superficial, in the form of separate islands, or deep, completely covering the surface of the tonsils. They can also spread beyond the tonsils: to the arches, uvula, to the mucous membrane of the nose and pharynx. Necrosis is often dirty gray or greenish in color. They disappear slowly, within 7-10 days. Catarrhal and follicular angina passes in 4-5 days.

Depending on the severity of the oropharynx lesion, regional lymph nodes are involved in the process. They become dense and painful upon palpation. The tonsillar and anterior cervical lymph nodes are the first to enlarge.

At the beginning of the disease, the tongue is dry, thickly coated with a grayish-brown coating, from the 2-3 day it begins to clear from the tip and sides, becomes bright red, with prominent swollen papillae, which makes it look like a raspberry: "raspberry", "papillary", "scarlet fever" tongue. This symptom is clearly detected between the 3rd and 5th day, then the brightness of the tongue decreases, but for a long time (2-3 weeks) it is possible to see enlarged papillae.

Usually, intoxication is manifested by a rise in body temperature, lethargy, headache, and repeated vomiting. In severe cases, body temperature rises to 40 °C, there is a severe headache, repeated vomiting, lethargy, sometimes agitation, delirium, convulsions, and meningeal symptoms. Modern scarlet fever is often not accompanied by intoxication with normal body temperature.

White dermographism in scarlet fever at the beginning of the disease has an extended latent period (10-12 min) and a shortened (1-1.5 min) apparent period (in a healthy person, the latent period lasts 7-8 min, and the apparent period - 2.5-3 min). Later, the latent period shortens, the apparent period becomes more persistent.

Neutrophilic leukocytosis with a shift to the left is noted in the peripheral blood; ESR is elevated.

Forms

Scarlet fever is divided by type, severity and course. By type, typical and atypical scarlet fever are distinguished.

• Typical forms include those with all the symptoms characteristic of scarlet fever: intoxication, sore throat and rash.

Typical forms are divided into mild, moderate and severe. Severity is determined by the severity of symptoms of intoxication and local inflammatory changes in the oropharynx. In recent years, scarlet fever has been mild in most cases, less often moderate. Severe forms are almost never observed.

• Atypical forms include mild, latent forms with mild clinical manifestations, as well as extrapharyngeal forms (burn, wound, and postpartum) with a primary lesion outside the oropharynx. With extrapharyngeal scarlet fever, the rash appears and is more intense at the site of entry, there are symptoms of intoxication: fever, vomiting. There is no sore throat, but there may be mild hyperemia of the mucous membrane of the oropharynx. Regional lymphadenitis occurs in the area of entry and is less pronounced than with typical scarlet fever.
• The most severe forms, hemorrhagic and hypertoxic, can also be classified as atypical.

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Diagnostics of scarlet fever in a child

In typical cases, diagnosing scarlet fever in a child is not difficult. Sudden acute onset of the disease, fever, vomiting, sore throat when swallowing, delimited hyperemia of the arches, tonsils, uvula, pink punctate rash on a hyperemic background of the skin, pale nasolabial triangle, enlarged regional lymph nodes of the neck provide grounds for clinical diagnosis of scarlet fever. An auxiliary method can be the picture of peripheral blood: neutrophilic leukocytosis with a slight shift to the left and increased ESR.

Difficulties in diagnosing scarlet fever arise in latent forms and when the patient is admitted to hospital late.

In latent forms of scarlet fever, limited hyperemia of the oropharynx, signs of lymphadenitis, white dermographism and the picture of peripheral blood are of diagnostic significance.

In case of late admission of the patient, long-lasting symptoms are diagnostically important: "raspberry" tongue with hypertrophied papillae of the tongue, petechiae, dryness and peeling of the skin. Epidemiological data are very important in such cases - contact of the child with a patient with other forms of streptococcal infection.

For laboratory confirmation of the diagnosis of scarlet fever, it is important to isolate beta-hemolytic streptococcus in mucus cultures from the oropharynx, as well as to determine the titer of antistreptolysin-O, other enzymes and streptococcal antitoxins. Scarlet fever is differentiated from pseudo-tuberculosis, yersiniosis, staphylococcal infection accompanied by scarlet fever-like syndrome, toxic-allergic condition, measles, meningococcemia, enterovirus exanthema, etc.

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Treatment of scarlet fever in a child

Patients with scarlet fever are hospitalized according to clinical and epidemiological indications.

• Hospitalization is mandatory in severe forms of scarlet fever and when it is impossible to isolate the patient and create conditions for his treatment at home. Patients with scarlet fever are placed in boxes or wards for 2-4 people, filling them at the same time. Contacts between newly admitted patients and convalescents must not be allowed. Discharge from the hospital is made according to clinical indications after the end of the course of antibiotic therapy, usually on the 7th-10th day from the onset of the disease.
• Patients with mild and moderate forms are treated at home. When treating at home, it is necessary to isolate the patient in a separate room and observe sanitary and hygienic rules when caring for the patient (current disinfection, individual dishes, household items, etc.). It is necessary to ensure compliance with bed rest during the acute period of the disease. The diet should be complete, with a sufficient amount of vitamins, mechanically gentle, especially in the first days of the disease.

In case of scarlet fever, antibiotic treatment is indicated. In the absence of contraindications, penicillin remains the antibiotic of choice. The duration of the antibiotic therapy course is 5-7 days.

Tomicide has a specific bactericidal effect against gram-positive cocci. The drug is used externally for gargling, 10-15 ml 5-6 times a day.

When treating scarlet fever in a child at home, phenoxymethylpenicillin is given orally at a rate of 50,000 IU/kg per day in 4 doses. In a hospital, it is more appropriate to administer penicillin intramuscularly in 2 doses. In severe forms, the daily dose of penicillin is increased to 100 mg/kg or more or they switch to treatment with third-generation cephalosporins. Probiotics (Acipol, etc.) are prescribed simultaneously with the antibiotic.

Prevention

Specific prevention of scarlet fever has not been developed. Preventive measures include early detection and isolation of patients with scarlet fever and any other streptococcal infection. According to the instructions, patients with scarlet fever are isolated for 7-10 days from the onset of clinical manifestations, but those who have recovered from the disease are allowed to be sent to a children's institution 22 days after the onset of the disease due to the possibility of various complications. Patients with other forms of streptococcal infection (tonsillitis, pharyngitis, streptoderma, etc.) in the scarlet fever outbreak are also isolated for 22 days.

For specific prevention of scarlet fever and other respiratory streptococcal infections among contact persons, the use of Tomicide is indicated. Tomicide is used as a gargle (or irrigation) of the throat. For one gargle, 10-15 ml of the drug or 5-10 ml for irrigation of the throat are used. The drug is used after meals 4-5 times a day for 5-7 days.

Since scarlet fever currently occurs almost exclusively in a mild form and does not give complications, especially when treated with antibacterial drugs and following the regimen, these decreed periods of isolation of those who have had scarlet fever can be reduced. In our opinion, patients with scarlet fever should be isolated for no more than 10-12 days from the onset of the disease, after which they can be admitted to an organized group.

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Forecast

The prognosis is favorable with rationally administered therapy (early penicillin therapy under conditions that exclude reinfection), the course of the disease is smooth, complications occur rarely.

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