Question

Illness

“Jose, maybe you should go to CVS and see if they have something to help with your fever.” Jose was sitting in the family room crying louder by the minute. He has been this way for a few days. “I am starting to worry because he seems hotter than a couple of days ago, and is now complaining about not being able to swallow because of the pain,” the mother exclaimed. Moreover, his teacher said that lots of other kids in his kindergarten class have been staying home sick. She said that they are usually ‘out’ for a week.

Admittance

Over the next couple of days Jose’s condition exponentially worsened. He was rushed to the Eisenhower ER. A Resident made the following notes from the initial physical exam and lab tests:

Jose Lopez – Initial Report

DOB: 11-16-2006

Gender: Male - Weight: 45.2 lbs. - Height: 42 inches

PHI: 6 yo Hispanic male presents to ER with complaints of throat and ears hurting. Patient very agitated, fussy, and complaining that he cannot swallow with persistent cough. Parents report onset as 6 days ago with focus on throat only, with persistent and progressive pain every day. Mother reports increased sickness of his kindergarten class. Pain is described as burning and scratching by child with nothing alleviating any pain beyond the mint tea parents made.

Allergies: NKDA

Med Hx: Untold herbals, no Rx/OTC; Mother noted to contact local herbalist for list

FH/SH: Nothing disclosed by parents (some inherent distrust of Western medicine and slight language barrier); patient lives with parents and attends kindergarten

Vitals: T 39.9 degrees C, BP 110/71 mmHg, RR 40bpm, Pulse 110bpm

Physical exam:

(+) Drowsiness, agitation, opthorrhea, rhinorrhea, cough

(-) Epiglottitis, flushing, impetigo, circumoral pallor, rash, erysipelas

*Pharyngeal erythema with petechiae and dark white tonsillar exudates, tender, hypertrophied cervical lymph nodes

Initial Laboratory Results:

WBCs: 11,800/uL, Differential: 78% PMNs, 18% bands, 4% monos

Chest X-ray: clear

Urinalysis: hematuria, proteinuria

Throat and blood cultures pending

Plan: Consult Supervising Physician for optimal treatment

Progress

Before rounding with the care team this morning, you (the nurse) have a chance to meet with Jose and his parents. You decided to look up the progress notes made on him and find the following:

Day 0: Started on empiric therapy of Penicillin VK per Dr. Wong’s recommendations. Fever still persists but less agitation and runniness are noted, and improved diet and fluid intake is noted by nurse Susan. Around 2300, the nurse Susan alerted Dr. Wong to a rash on Jose’s trunk and empiric therapy is discontinued.

Day 1: The throat culture on sheep blood agar revealed Streptococcus pyogenes (Streptococci) and Jose was given a diagnosis of streptococcal pharyngitis (strep throat). Blood culture confirms S. pyogenes. Gentamicin is initiated by the nurse with renal dosing per doctor. ECHO (diagnostic ultrasound) is scheduled for next afternoon.

Questions

Why would an ECHO be scheduled for Jose? What other tests should be run to minimize potential complications?

The urinalysis suggests distress at the level of the kidneys. What type of hypersensitivity is associated with an infection that becomes systemic to this degree? Explain the hypersensitivity.

What could be the potential cause(s) of Jose’s rash?

Is gentamicin an appropriate agent for this patient? Why or why not? If not, what would you choose to replace it? (For either choice, include safety/efficacy monitoring param

Answer 1

Streptococcal pyogenes causes autoimmune-mediated complications like  rheumatic fever . That is why echo is scheduled for patient. and acute post-infectious glomerulonephritis.

other test to diagnose complications are erythrocyte sedimentation rate, ECG, c reactive protein, renal function tests

Type III hypersensitivity caused renal distress . It occurs when there is accumulation of antigen-antibody complexes that have not been adequately cleared by innate immune cells, giving rise to an inflammatory response and attraction of leukocytes.

potential cause of rash can be scarlet fever along with streptococcal pyogenes infection.

Gentamicin is not an appropriate drug for this patient as patient is not showing symptoms of streptococcal pyogenes induced glomerulonephritis and gentamicin is on nephrotoxic drug.

pencillin or amoxicillin can be used to replace gentamicin.efficacy of Administering antimicrobial therapy will be seen in more rapid clinical improvement and will decrease person to person transmission. It will prevent suppurative and some non-suppurative complications such as rheumatic fever.