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.

Respond to the following:

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 parameters.)

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

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

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

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

What are some of the microbiological properties and virulence factors produced by this pathogen? Explain the typical mode of transmission and the epidemiological properties.

Answer 1

1) Gentamycin may not be the ideal choice for this patient since this patient has both throat cultures and blood cultures growing streptococcus pyogenes . gentamycin acts well on extracellular located organism but makes it difficult for intracellular organism to be inactive .this gentamycin may not act appropriately.The options for penicillin allergy in care of streptococcus pharyngitis is a narrow spectrum cephalosporin like cefadroxil .it is excreted through the kidneys so renal function should be monitored and dose should be adjusted accordingly.chances of hypersensitivity is possible look for rash, breathing difficulty, anaphylaxis.

2) potential cause for Jose rash could be due to penicillin allergy which is evidenced by an anaphylactic reaction like rash, breathlessness,.

3)The hypersensitivity is called as nephrotoxicity where the renal system is being affected by the use of penicillin and the baseline urine analysis shows proteinuria which could be suggestive of a nephrotix syndrome.

4) An Ultrasound is essential to diagnose streptococcus glomerulonephritis which is a complication of a streptococcus pyogenes throat infection. Which can be seen as an hyper echoic location in kidneys . test like creatinine,BUN, electrolytes complete renal function should be checked to ascertain the diagnosis of glomerulonephritis.