Transcript An Unusual Presentation of Group A Strep Infection

Fever, sore throat and
chest pain in a 9 year
old.
Angie Hartsell, MD
David Fitzgerald, MD
Wednesday ID Case Conference
March 12, 2008
HPI
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Pt is a 9 yo previously healthy male who presented to the emergency
department with a 1 week history of cough, rhinorrhea, chest pain,
fever and sore throat.
He had diarrhea and vomiting for the initial 2-3 days of his illness, but
this resolved.
He describes the chest pain as sharp and located at the sternal notch.
His chest pain and fever have gotten worse as his other symptoms are
improving.
He describes waking up sweaty for the past 5 days.
He denies difficulty breathing, wheezing, or stridor.
He does admit to a change in his voice. He denies dysphagia or
odynophagia. He admits to “spitting a lot” over the past 2 days.
He has had decreased appetite and energy, but is drinking normally.
Admits to 2 lb weight loss over the last 4 months. His mom and two of
his aunts are sick with upper respiratory infections.
HPI
► Medications:
steroid cream for eczema
► Allergies: NKDA
► PMH: Eczema. No prior hospitalizations or
surgeries.
► FMH: Maternal uncle with asthma, otherwise
negative.
► SHX: Lives with his mom, sister, and a
cousin. No smokers. No pets. He’s in the
4th grade.
Physical Exam
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Temp 103.1, HR 128, BP 113/72, RR 18, O2 sat 96 % on
RA.
General: breathing comfortably and in no apparent
distress. He was non toxic appearing.
HEENT: NC/AT, PERRL, sclera and conjunctivae clear.
Small amount of clear drainage from his nares. His lips
were dry but not cracked. His orophaynx was moist with
mild erythema but no exudates. His TMs were normal
bilaterally.
Neck: soft, supple, without lymphadenopathy.
CV: RRR, no m/r/g.
Chest: His lungs were clear bilaterally with good air
movement and no wheezes, rales, rhonchi.
Physical Exam
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Abd: Bowel sounds were present. His abdomen was soft,
non tender, non distended, without hepatosplenomegaly.
GU: Genital exam showed normal tanner I male with testes
descended bilaterally. He had dry skin flaking off of his
testicles, but not involving the urethra. He had circular
desquamation surrounding the anus, so that the skin was
pink in a 4-5 cm diameter.
Skin: His palms were desquamated in thick sheets and he
was actively picking at the skin. The skin on his feet were
intact with no signs of desquamation.
EXT: He had normal pulses and capillary refill time was less
than 2 seconds.
Neuro: Grossly intact. Non-focal.
Labs
► CBC
 30.7>11.1/32.1<441 87% neutrophils, 9%
lymphs
► Na
129, K 3.1, Cl 92, CO2 23, BUN 13, Cr
0.85, Ca 8.6, Tprot 7.4, Alb 2.2, AST 52
Discussion
Follow-Up
► Patient
was sent to WFUBMC where he
received antibiotics and broke out in a
scarlatinaform rash
► He received IV Unasyn and surgical
drainage by dorsal thoracotomy.
► Cultures sent grew Group A Strep.
► He was discharged after 5 days on 14
additional days of Augmentin.
Mediastinitis
► Anatomic
Anatomic considerations
► The
region between within the thorax
between the pleural sacs extending from
diaphragm to superior aperture of thorax
► Three major routes of spread of infection
from head and neck to mediastinum include
 1. pretracheal space
 Long fascial planes of posterior neck
 Viscerovascular or lateral pharyngeal space
Causes of acute mediastinitis
► Mediastinitis
due to infections of the head and
neck and contiguous structures
 Esophageal perforation
 Head and Neck infections – odontogenic, Ludwigs
angina, pharyngitis, tonsillitis, parotitis, epiglottis,
lemierre’s syndrome
 Infections originating at other sites – Pneumonia,
empyema, pancreatitis, cellulitis of chest wall, lymph
node necrosis and hemorrhage (anthrax) or casseous
necrosis (TB)
► CT surgery
► Histoplasma
can cause a sclerosing mediastinitis
Microbiology of mediastinitis
► Head
and neck – largely polymicrobial, often
synergistic infection made up of a number of oral
anaerobes and GNR
 Anaerobic – peptostrep, actinomycese, bacteroides,
fusobacterium, Prevotella, Porphyromonas
 Aerobic Strep, Staph, diphtheroids, GNR, Candida
► CT
surgery – largely GPC (less GNR)
 Staph aureus, Epi, Enterococcus, Strep, many others
Microbiology of mediastinitis
► CT
surgery – largely GPC (less GNR)
► Staph aureus, Epi, Enterococcus, Strep
Clinical presentation
► Usually
will have obvious primary infections
with pain , fever and swelling at primary site
► Also chest pain, resp distress and
odynophagina
► Hamman’s sign – a crunching rasping sound
heard over the precordium with heartbeat
► Crepitus in supraclavicular region
Treatment
► Prompt
surgical drainage and appropriate
antibiotics directed against mixed
oropharyngeal infection
► Complications
► See
of Tonsillitis
Table I in: Bell, Z, Menezes AA,
Primrose, WJ, McGuigan, JA. Mediastinits: a
life threatening complication of acute
tonsillitis. J Laryngol Otol. 2005 Sep; 119
(9), 743-5.
► Complications
mediastinitis
► See
of descending necrotizing
Table II in: Bell, Z, Menezes AA,
Primrose, WJ, McGuigan, JA. Mediastinits: a
life threatening complication of acute
tonsillitis. J Laryngol Otol. 2005 Sep; 119
(9), 743-5.
Search PubMed
► Acute
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Mediastinitis
Case Reports
Review
Differential Diagnosis
Therapy
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