Scarlet Fever – PediaCast 103
- Dr Michelle joins us again!
- We continue our discussion of the classic childhood exanthems.
- Today's focus is 2nd Disease, better known as Scarlet Fever.
Announcer 1: Bandwidth for Pediacast is provided by Nationwide Children's Hospital, for every child, for every reason.
Announcer 2: Welcome to Pediacast, a pediatric podcast for parents. And now, direct from Birdhouse studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome to Pediacast. It's episode 103 for Thursday, January 24th, 2008. Scarlet Fever. It's Dr. Mike coming to you from Birdhouse studio and I'd like to welcome everyone to the program.
Dr. Michelle is going to be joining us in just a few moments, so we're going to have a discussion on Scarlet Fever. So that is coming up.
I want to make a pitch here real quick on expensive lab tests. Now what in the world am I talking about. Well,
because it's an interview show, I wanted to put a little bit more material into the show than just scarlet fever. So this
is going to be a little bit of a longer introduction than usual. But I actually got some information and a bit of a rant
from me. In medical school, and I know we have medical students who listen. I was taught, and I'm sure that you're
taught, to only order lab tests if changes medical decision-making.
Rapid strep test would be a classic example of this. So, if you have a positive rapid strep, you're going to treat with
an antibiotic. If you have a negative rapid strep, you're probably going to presume that it's a virus and you're not
going to treat with an antibiotic. So, the rapid strep test was worth it because you acted on the information that it
had obtained. Positive, you treat. Negative, you don't treat. And then we follow the negatives up usually with a
throat culture because they are not 100% accurate.
And if the throat culture comes back positive, you're going to treat with an antibiotic. And if it comes back negative,
then you feel better about the fact you're saying it's a virus. So, you know, the throat culture is a good test order
because you're going to base a medical decision on it so it's worth the money. And we're going to talk a lot more
about strep coming up in just a few minutes.
And then we also have a rapid RSV test. Rapid RSV is respiratory syncytial virus. We should do a show on that
here at some point soon, because it's important this time of the year, and I'm sure many of you have heard about it.
But the treatment for this is the same whether you have a positive or a negative result. So, classically you would say
that getting an RSV test is not worth the money because you're not going to do anything with the information. You're
not going to base any medical decisions on the information. You're going to treat them the same, whether it's
positive or negative. They're wheezing, you're going to deal with their wheezing. We also have a rapid flu or
Now, that one is useful if it's in the first day or two of their symptoms because you can put folks on Tamiflu, an
antiviral medication that helps to get rid of the flu virus in your body. But beyond that, treatment is the same
regardless of the test outcome. So if you have a person who comes into the office and they are 4 or 5 days into their
illness, Tamiflu is probably not going to help them and getting the rapid flu test is really a waste of money if you look
at it in terms of are you going to base a medical decision on the outcome of the test.
We also have a test for rotavirus and again, it's a virus; treatment's the same regardless of the outcome. So really,
it's not helping you with any medical decision-making. So, I was taught that these tests are generally a waste of
money and if you are not basing any medical decision on the result, then we shouldn't be ordering them. And I'm
sure that a lot of you were taught the same thing. But, as you practice some number of years, you know, you develop a style. You are influenced by those you practice with, so you pick up good habits and you pick up some bad habits, and I know do get many of these so-called worthless tests.
And some circles, you know, will say my partners have led me to bad habits in this regard. But I do feel they are
helpful and useful in helping parents understand. RSV and the flu and rotavirus last a long time. I mean, these viral
infections are once that can easily last two to three weeks in the kids who have them. The viral infections, there's
little that we can do to help them, you know, other than symptom relief and to make sure that more serious
complications aren't arising but there's nothing that we can do to help the body fight the infection any faster, except
in the case of the flu right at the very beginning if you catch it in the first day or two.
But you know, the thing is, when there is a prolonged illness and the kids are not getting any better after a couple of
weeks, and the doctor tells the parents, "Yeah, I'm pretty sure it's X,Y, or Z," "Yeah, I'm pretty sure it's RSV," "Yeah,
I'm pretty sure it's the flu," or "I'm pretty sure it's rotavirus," parents don't like this lack of a hundred percent certainty.
I mean, it's kind of a sign of weakness if the doctor doesn't say this is what it is, and it makes moms and dads kind
of nervous and they keep coming back because they want another opinion. And you know, by getting the test, at
least we can say, it is X, Y, Z. It's going to last two to three weeks. Here are the signs that make me concerned. If
they happen, let me know. Yeah, you spend money, but you also save money by reducing repeat visits when you
don't need. They also help come parent anxiety. They kind of calm doctor anxiety, too, when you can tell the parent
this is what it is. Okay so there. My own justification for ordering tests that aren't medically necessary. [Laughs] All
these little things we have to think about.
Alright Dr. Michelle is going to join us, coming up here in a couple of minutes as we continue our discussion of the
classic childhood exanthems. Today's focus is "second disease" or better known as "Scarlet Fever." That's coming
Don't forget, the information presented in Pediacast is for general educational purposes only. We do not diagnose
medical conditions or formulate treatment plans for specific individuals.
If you have a concern about your child's health call your doctor and arrange a face to face interview and hands on
which you can find at Pediacast.org. With that in mind, we will be back with Dr. Michelle, right after this short break.
Alright, in the United States each year, more than 10 million patients are diagnosed with acute pharyngitis, over half
of which are caused by viruses.
Bacteria cause the remainder of cases and group A streptococcus is the most common of these, accounting for
25% to 30% of all episodes of pharyngitis overall . A group A strep peak occurrence is during the late winter and
early spring, but it can occur year-round and most often occurs in children ages 5 to 15 years. While morbidity and
mortality from streptococcal pharyngitis, also known as "strep throat," is extremely rare, the complications of this
disease can result in significant illness. In developing countries, rheumatic heart disease accounts for 25 % to 40%
of all cardiovascular problems.
Scarlet fever is another problem and it's a skin complication seen in approximately 10% of those strep pharyngitis.
And here to talk with us about Scarlet fever and strep throat is Dr. Michelle, a good friend of the show and a third
year Family Practice resident in Hawaii. So welcome back to Pediacast, Dr. Michelle.
Dr. Michelle: Thanks, Dr. Mike. Good to be back.
Dr. Mike Patrick: For those of you who are just joining us, because may be you got an iPod for Christmas and you just found Pediacast.
Dr. Michelle: [Laughs]
Dr. Mike Patrick: Back a couple of months ago, Dr. Michelle joined us and we talked about the classic childhood
exanthems, sort of if you go back in the history, the major rashes that kids get, and back then, they just named them, first disease, second disease, third disease, fourth disease down the line. And the last time Dr. Michelle joined us,
we talked about first disease which was measles. And this time we're going to talk about second disease, which is
Scarlet fever. So, Dr. Michelle, why don't you go ahead and just start, and I guess the first thing to do would be to
talk about what we call epidemiology, just sort of who gets it, how they get it, why they get it, that sort of thing.
Dr. Michelle: Sure thing. Well, as you noted, most often it occurs in children age 5 to 15 or so. But it can occur in
anybody at any time, and again, we're in peak season right now being the end sort of time of winter, beginning of
And people who get it are often in more enclosed living conditions, because it is spread person to person.
Dr. Mike Patrick: Right.
Dr. Michelle: So, a lot of school age children hence the 5 to 15 years of age. You can also have outbreaks in
homeless communities or in college dorm settings as well.
Dr. Mike Patrick: Right.
Dr. Michelle: Most often, it's– The good thing about strep throat is that it is self-limited, meaning that, it will go away
on its own. The bad thing is that if we don't treat, you can get some complications. So that's why it's a big deal.
Dr. Mike Patrick: Right. And I think that's important for people, and I know when we get to the treatment part– [Laughs] I'm
kind of jumping ahead here, but one of the things that parents when they come to see the doctor want is an
antibiotic, and really, with strep throat when you use the antibiotic even, it doesn't get better that much faster.
Dr. Michelle: No, maybe one day.
Dr. Mike Patrick: [Laughs]
Dr. Michelle: All the studies have shown approximately 24 hours.
Dr. Mike Patrick: So you don't–
Dr. Michelle: I guess that's 24 hours less of a sore throat.
Dr. Mike Patrick: Right.
Dr. Michelle: But it's not a huge difference.
Dr. Mike Patrick: Right. And so, folks, that's not, "you'll get better in 24 hours." That's, "you'll get better 24 hours quicker than you would if you didn't use an antibiotic at all."
Dr. Michelle: Right. So your sore throats still going to last for 4 or 5 days.
Dr. Mike Patrick: But it's still important to go see your doctor and get treated and we'll get to it exactly why here soon.
Dr. Michelle: Sounds good. The other important thing about being treated, though — it does reduce the spread of
Dr. Mike Patrick: Right.
Dr. Michelle: So, in addition to the complications.
Dr. Mike Patrick: And then how long are you contagious if you have strep throat after you start the antibiotic.
Dr. Michelle: 24 hours after you start the antibiotic, you can stop being contagious and go back to school.
Dr. Mike Patrick: 24 hours.
Dr. Michelle: I know all the kids who heard that didn't want to hear that, but only 1 day. It only takes 24 hours and you
stop being contagious.
Dr. Mike Patrick: [Laughs] You know, and this is going off-topic, but it just reminded me. It's funny, the kids that I see, half of
them, you tell them you can't go to school tomorrow, because they have to be on the antibiotic for 24 hours, and it's
like, "Yipee!" And there's a group of kids who are really upset about that.
Dr. Michelle: Yes, you do. You do get those kids who feel that if miss even one day, they fall behind.
Dr. Mike Patrick: And then you get those kids who've had perfect attendance, and it's April, almost the end of the school
year and I'm not a big fan of the perfect attendance award, personally.
Dr. Michelle: Don't they have a big award, too, for perfect attendance all four years of high school or something as
Dr. Mike Patrick: Yes, yes. A lot of them do and that's just not reasonable.
Dr. Michelle: That's– How can you not be sick at all for four years?
Dr. Mike Patrick: Yes. I don't get that.
Dr. Mike Patrick: I'm not sure that's something that should be rewarded. Oh well.
Dr. Michelle: I don't know, although, both of us being doctors, you have to be pretty sick as a doctor to take a day off because–
Dr. Mike Patrick: Oh right. Yes.
Dr. Michelle: The instant we take a day off, there's chaos.
Dr. Mike Patrick: Yes, that's true. Good point.
Dr. Mike Patrick: It puts a big burden on the other doctors. Okay, but anyway we're going on off on to–
Dr. Michelle: Indeed. Very, very tangential today
Dr. Mike Patrick: Yes, yes. So where were we? We were talking about epidemiology. [Laughs]
Dr. Michelle: Right, so let's talk a little bit about the infection itself as caused by streptococcus and I know you have
some medical people who listen like med students, so I'll just give them a quick rundown. It's a gram-positive cocci, grows in chains, and there are three kinds: the alpha-hemolytic, the beta hemolytic, and the gamma-hemolytic. And
those are all just, how they culture out. So the group A streptococcus is beta-hemolytic.
Dr. Mike Patrick: Okay, what does that mean?
Dr. Michelle: When it's cultured out and grown in the lab, it breaks down the area fully around it versus alpha-
hemolytic which only breaks down around it a little bit.
Dr. Mike Patrick: Right.
Dr. Michelle: And a gamma-hemolytic doesn't break it down at all.
Dr. Mike Patrick: Right. And I think, when they do these cultures, I think it's sheep's blood, isn't it? They give some of
Dr. Michelle: I believe so.
Dr. Mike Patrick: So the bacteria has a toxin in it that's able to break apart red blood cells from sheep and so, the red sort
of disappears around on the culture plate.
Dr. Michelle: Right.
Dr. Mike Patrick: Okay. Alright, and what is it about– Well, I guess, first, what exactly is Scarlet fever.
Dr. Michelle: Well, Scarlet fever is the result of– They haven't definitively decided what's the cause of it, but they do
think it is part of antigenic mimicry and what that means is that when our body's immune system revs up against an
infection, it gets a little confused because sometimes those little pieces of the offending agent can look similar to
our own body parts, so then the body's immune system gets a little confused and attacks itself a little bit.
And Scarlet fever is the result when the body attacks its own skin a little bit.
Dr. Mike Patrick: So this is in the realm of autoimmune kind of disorders, for the medical people. [Laughs]
Dr. Michelle: Exactly. And the fancy terms for it is antigenic mimicry leading to autoimmunity. There is an
erythrogenic toxin–erythrogenic is a fancy term meaning, "making red." So, there's a red-generating toxin that is
often seen in kids more than adults and that's what causes the red color of the rash.
Dr. Mike Patrick: Great. And what do we describe this rash a little more, just in terms of what it looks like with Scarlet fever.
Dr. Michelle: Sure. The classic thing you'll see in the medical books are like a sunburn with goosebumps. You know,
it's sandpaper-like in texture, it's very coarse, it's red and it blanches.
So, when we talked about rashes initially, we talk about blanching. When you push on it, it loses its color.
Dr. Mike Patrick: Right. And what other signs and symptoms go along with the rash, with Scarlet fever? [Laughs]
Dr. Michelle: Oh, the big one is Pastia's lines. These are red streaks that occur in the skin folds. Often in the axilla,
which is the armpit or the groin, and they can also occur in the abdominal creases or in like the crease of your
elbow. Other signs that you look for with Scarlet fever rash are, it starts in the chest and spreads outward, including
a flushed face. But it tends to spare the area around the lips.
Dr. Mike Patrick: Right. So that's why you can tell it apart from other rashes.
Dr. Michelle: Right. That helps us out a lot.
Dr. Mike Patrick: Sure.
Dr. Michelle: And, approximately a week, maybe 10 days or so after the rash appears, it can start to peel off and the
peeling starts on the face and then spreads downward, and a peeling can last over a month.
Dr. Mike Patrick: Because you basically have to make new skin where the peeling took place.
Dr. Michelle: Right.
Dr. Mike Patrick: And it takes a while to do that. So basically this happens a lot because you– You use the word Scarlet
fever in the office and everyone kind of gasps and takes a step back.
Dr. Michelle: [Laughs]
Dr. Mike Patrick: But Scarlet fever, really, itself isn't all that dangerous. Rheumatic fever is the dangerous complication that
you get from strep, not Scarlet fever. So, Scarlet fever really is just strep throat with the fever and with the rash.
Dr. Michelle: Exactly.
Dr. Mike Patrick: Right. Now, does it have to be strep throat? Can you have a strep infection somewhere else in the body
that could cause Scarlet fever?
Dr. Michelle: Of course. Most common would– After the throat infection would be a skin infection which often call
Dr. Mike Patrick: Right. So, sometimes, they'll come in with this rash that looks sort of classic for a Scarlet fever and you
look in their throat, it's fine, they don't have sore throat and then you've got to sort of inspect the body pretty closely
to try to figure out where this is coming from.
Dr. Michelle: Kids do hide the impetigo well.
Dr. Mike Patrick: That's right
So, Scarlet fever — it's pretty common and now are there other things that can cause rashes that look like Scarlet
fever. I mean if you see a rash that sort of looks like the classic sandpaper rash, it's in the right distribution, and they
have a fever with it, do you just assume that it's strep and treat them, or are other things that could do it too.
Dr. Michelle: Of course, there are other things. And this is why we always send everybody to the doctor to get a look
at it instead of just calling in.
Dr. Mike: & That's right, that's right.
Dr. Michelle: Any of the other childhood rashes that we've been talking about can cause it: measles, rubella, mono
can cause a rash like this; even severe sunburn could even look similar to this.
Dr. Mike Patrick: Right. So there are other things. Go ahead. I'm sorry.
Dr. Michelle: One of the things that could like it, that would be dangerous, are the toxic shock syndrome.
Dr. Mike Patrick: Yes, and what causes that usually?
Dr. Michelle: Staph, usually.
Dr. Mike Patrick: Yes that's right. So it's definitely not something you want to just say, "Oh I know what Scarlet fever looks
like. I'm going to call the doctor and say 'he has Scarlet fever, call me an antibiotic. "We're going to make you come
Dr. Michelle: Absolutely.
Dr. Mike Patrick: Right. So let's say that you have someone with Scarlet fever or with a really bad looking throat even if they
don't have a Scarlet fever. How do you go diagnosing strep?
Dr. Michelle: Well, there are a couple of different ways. We have the rapid strep test these days. I'm sure a lot of
parents are familiar with that. It's something that it's often done in your doctor's office and it's fairly sensitive –& up
98%. But it doesn't always catch all the strep throats. So often, we'll get a culture at the same time of the throat to
Dr. Mike Patrick: Right. It depends on the specific rapid strep test that we are talking about, and then also it depends a little
bit on the technique of the person obtaining the swab. But in general, in our office, we get about a 95% sensitivity
with this, so about 5% false negative rate. But we still do follow-up cultures on everybody.
Dr. Michelle: And then there's also corner criteria, which our medical listeners will be happy to hear about. It is a
clinical diagnosis and there are four corner criteria: fever, anterior cervical adenopathy (so that's enlarged lymph
nodes in your neck), tonsillar exudates, and no cough.
Those are the four criteria for strep throat. If you only have two out of those four, there's a mild suspicion for strep
throat but if you have three or four out of the four, it's presumed to be strep throat.
Dr. Mike Patrick: And if you have those and the Scarlet fever-looking rash, then you're pretty convinced. [Laughs]
Dr. Michelle: Yes, there's really a limited questioning of that one. [Laughs]
Dr. Mike Patrick: Right, right. Now one thing that we see a lot is you have a kid who has a viral type upper respiratory
symptom and they'll have kind of a cough, runny nose, congestion and a fever, and their tonsils will be a little bit
enlarged and they are complaining of a sore throat and you swab them and they are positive for strep but their
illness may actually just will be the virus and you're picking up the carrier state–
Dr. Michelle: Right.
Dr. Mike Patrick: Because a lot of people have some dormant strep that live in the back of their throat. We still treat that and
try to get rid of it but just something else to point out that a lot of these kids, you start them on the antibiotic, they're
not getting better and it may not only be that the antibiotic only gives you a day off of the link of strep, but it could be
that the antibiotic is not doing anything for the real symptoms because that's still are caused by the virus.
Dr. Michelle: Right, like you said before, only up to 30% of sore throats or pharyngitises our secondary to the strep.
Dr. Mike Patrick: Right, right. Now what about a blood test? Can you do a blood test to check for strep?
Dr. Michelle: Sort of. We can do and ASL, which is anti-streptolysin O titre. But that can't tell us if you're actively
having a disease. It only tells that you recently have had it. So you could have had a recent infection.
Dr. Mike Patrick: Right
Dr. Michelle: But it doesn't mean that's what you are having right now. Right.
Dr. Mike Patrick: So the listeners, especially moms and dads were probably thinking, well if you had it recently, who cares? &
Because it's over, it's gone. But it does help because if you suspect certain complications from strep, but you are
not sure if that's really what's going on or not, it is helpful to know that there was perhaps a recent strep infection that
the parents and child and doctor didn't know about.
Dr. Michelle: Right, because sometimes we don't. The patients don't come in or on occasion there are
misdiagnoses. So it is useful after the fact.
Dr. Mike Patrick: Right. Okay so let's– We have the patient that comes. They've got a Scarlet fever-looking rash, their throat
hurts, it's inflamed. We check a rapid strep, it's positive. So how do we treat Scarlet fever.
Dr. Michelle: Same way you treat strep throat –& with penicillin.
Dr. Mike Patrick: Okay.
Dr. Michelle: Group A strep is susceptible to penicillin across the board. We're very fortunate so far there's not been
a significant changes in that and then because penicllins do cause allergies in a fair number of people, we use
what's called a Macrol antibiotic for people who are allergic to penicillin. So that's going to be your erythromycin or
something along those lines.
Dr. Mike Patrick: Okay while we are talking about antibiotics, I want to mention a couple of things here real quick. In each
area of the country, you're going to have different resistance patterns sort of depending on the bacteria in that
community. For instance, in our particular community, the macrolides don't work very well. There's a lot of
resistance to group A strep with those. And people who have allergies, what I typically do, I will have them come
back for sure, just to make sure the strep is gone and let them know, hey if your throat is not feeling better in a few
days, make sure you call me and let me know. Because we really do see a lot of resistance to the macrolides in our
area. Of course, that's going to differ from place to place.
Dr. Michelle: Do you have a high number of penicillin-allergic patients in your area, too?
Dr. Mike Patrick: Not really. I mean, probably a normal number of those, so I don't know why the resistance pattern is there.
Now something else that's kind of interesting is we also see a fair number of kids who fail penicillin treatment.
And the ongoing hypothesis with this is that it's not that the group A strep is becoming resistant, it's that these
people have other bacteria in their mouths that are making a chemical that renders the penicillin ineffective.
Dr. Michelle: Right.
Dr. Mike Patrick: So you have to kill these other bacteria that are normal bacteria in the mouth. They just happen to be
making a chemical that renders the penicillin not effective so you got to step it up, you know like to cephalosporin or something, and that will usually take care of it.
Dr. Michelle: Yes.
Dr. Mike Patrick: Have you found that or no in Hawaii?
Dr. Michelle: No, we've– And in our practice we've had really good results with the penicillin. As far as I know there's
no significant problems with the penicillin or with the macrolides around here.
Dr. Mike Patrick: Yes. The success rate with the macrolides in our area ended up being about 75%-80% so there's about
20%-25% resistance with the macrolides and then I would say probably 10%-15% of the kids that I see that we put
on the penicillin, it doesn't work.
Dr. Michelle: I'll have to check with our hospital to see if they've had any recent studies on that.
Dr. Mike Patrick: Yes, yes.
Dr. Michelle: That's not been an issue out here.
Dr. Mike Patrick: Now, of course, with the macrolides, they can help you out there, but with this– I mean, because the group A strep in the culture, the penicillin, it's going to look like it works. But again, if they have these other bacteria in their mouth that are making beta-lactamase, then there's a problem.
Dr. Michelle: Right.
Dr. Mike Patrick: So. Okay. Well, in any case what other things do you do to treat strep?
Dr. Michelle: The rest is mostly symptomatic. Whatever it takes to make you feel better — throat sprays, lozenges;
there's the lidocaine; a viscous lidocaine that you can swallow to help numb up the throat.
Out here, a really big thing is salt water gargles — sea salt gargles.
Dr. Mike Patrick: Right.
Dr. Michelle: Patients will use that regularly. Lots and lots of fluids, making sure that kids are eating well and
maintaining their fluid intake.
Dr. Mike Patrick: Now what about taking tonsils out. Because that always– You know, you get a kid who has had a couple
of strep throats in a 6 month period and their parents are thinking, oh, it's time to take the tonsils out. Do we still do it
Dr. Michelle: Not as frequently as we used to.
Dr. Mike Patrick: Right.
Dr. Michelle: The aunties don't really jump on that as much especially out here. If there is several episodes
recurrent within the past year. They will consider it. But you have to have a fair number. I think they do it 7 to 10 within a year.
Dr. Mike Patrick: Yes, so and the reason for that is that more times that you have it, the chances increase for rheumatic
fever which we're going to talk about.
Dr. Michelle: Exactly.
Dr. Mike Patrick: Right. Okay so, and something else that I probably should mention is you can– when it doesn't go away,
so let's say the penicillin doesn't work or you get strep throat again a month, 2 months later, and you keep getting it, there is a possibility that you or someone in your house is a carrier, this is sort of going to be on the Scarlet —
[coughs] excuse me, my cough is still lingering remnants of it [laughter]. It's something that you got to get the
carrier state eliminated from the family and sometimes there are different antibiotics that we have to use for that like clindamycin and rifampin sometimes even to get rid of it.
Dr. Michelle: Right.
Dr. Michelle: Sorry my dog is guarding the–
Dr. Mike Patrick: [Laughs] The joys of podcasting.
Dr. Michelle: Sorry, everybody.
Dr. Mike Patrick: No problem. That kind of– I just got to have a look around [Laughs]. We don't have a dog.
Dr. Michelle: Meet Moby [laughs].
Dr. Mike Patrick: So in any case there are other antibiotics that you might get into with recurrent strep in trying to get rid of
it. And these were kids that probably had their tonsils out much quicker in years passed but now we'd go a little bit
more into trying to eliminate the carrier state in the house in order to get rid of it so then it doesn't keep coming
Dr. Michelle: Exactly, and just another thing to note it's that there's no prophylaxis for exposure. So just because one of your children has strep throat, doesn't mean that we're going to automatically give antibiotics to your other
children as well to prevent it.
Dr. Mike Patrick: Okay. Why don't we go ahead and go through some of the complications of strep and I'll try not to interrupt you too much with this because when I interrupt we go off on tangents and it goes much longer. So go ahead, why don't you go through the complications of strep.
Dr. Michelle: Sure. Well, let's talk about the biggest one first: acute rheumatic fever.
This is preventable when we treat the strep infection with a complete 10-day course of antibiotics. Otherwise, if we
don't treat it, about maybe up to 3% of patients will develop acute rheumatic fever. So that's why we treat strep so
religiously. So rheumatic can pop up approximately 2 or 3 weeks, maybe a month after you have your initial
infection. It's believe to be, again, autoimmune, with the mimicry like we talked about previously and it is an
inflammatory response by your body. We have what are called the modified Jones criteria that help us to diagnose this clinically and basically give us our symptomology. The five major Jones criteria are arthritis — this is a migratory arthritis — so what that means is it's starts one joint and then it goes away in that joint, goes to another joint and each joint lasts a couple of days and then it goes away.
Usually starting in the knees or lower extremities and then traveling upward and that can last up to a month and that goes away on its own most of the time. The second Jones criteria is carditis. So there are three different kinds of
carditis. Carditis is an inflammation of the area around the heart. There's pericarditis which is the sac-like membrane that surround your heart. There is myocarditis which is the muscular layer of your heart. And there's endocarditis which is the one people most commonly hear of which are the chambers and the valves of the heart — the lining of those things. This is probably the most feared of complications because it can result in a permanent
valvular damage within the heart. It usually goes after the mitral and/or aortic valves and can cause stenosis which is a narrowing of the valve. So that can inhibit the blood flow a bit.
The worst case scenario is it can cause acute cardiac compensation leading to heart failure.
Dr. Mike Patrick: So– I promised I wouldn't interrupt but–
Dr. Michelle: That's okay.
Dr. Mike Patrick: So this is why even though only 3% of cases of strep pharyngitis can lead to rheumatic fever, this is why
we treat everybody because this is such as a very bad, bad thing.
Dr. Michelle: It is, and this is so bad and it can occur years after the initial infection.
Dr. Mike Patrick: Right.
Dr. Michelle: So that's kind of scary that it can pop up on you like that.
Dr. Mike Patrick: Right, right.
Dr. Michelle: So the third Jones criteria is Chorea, which–
Dr. Mike Patrick: Not the country.
Dr. Michelle: Not the country. No. It's spelled with a C-H, not a K.
Dr. Michelle: And these are uncoordinated, jerky movements. They affect the upper extremity, the face, often are just on one side of the body.
I remember being in medical school and the picture that they showed us was of somebody
holding a flashlight and you see the flashlight jerking around — my random medical school memory.
Dr. Michelle: There's muscle weakness and some emotional instability as well. The fourth Jones criteria is the
subcutaneous nodule. Those are exactly what they sound like. They are kind of little bumps that occur right under the skin so they cause your skin to rise up and then the fifth one is another manifestation called erythema marginatum and it's kind of a travelling rash. It's a little ring or snake curvy kind of appearing skin eruption, and it can appear, disappear, reappear, go different places and that can go on for a couple of months.
Dr. Mike Patrick: Right. So do you have to have all five of these things in order to have rheumatic fever?
Dr. Michelle:& No. The way we actually diagnose rheumatic fever is we get the blood test, the ASL that we talked
about a little bit ago to prove that there was a recent infection. And then we have the presence of two of those
criteria that I just talked about. So two of those major criteria or one of the major ones and two minor ones and the
minor criteria include fever, joint pain that doesn't qualify for arthritis because arthritis is actually inflammation; high
levels of inflammatory markers in the blood or EKG changes.
Dr. Mike Patrick: Okay. Now so let's say you do have someone with rheumatic fever, what do you do about that? I mean,
they are just destined to have these heart issues.
Dr. Michelle: Well we hope not. We end up giving them antibiotics monthly. So we give them a monthly penicillin
shot to try and prevent recurrences of these.
For kids we usually go until they reach adulthood age 18 or 21 and then for adults we often go for 5 years where
they have to get monthly shots.
Dr. Mike Patrick: So this is definitely something you want to avoid. [Laughs] There's no question about it.
Dr. Michelle: At all costs. Absolutely.
Dr. Mike Patrick: This is why when you call the doctor and you say you have a sore throat, come on in. We've got to see you.
Dr. Michelle: Exactly.
Dr. Mike Patrick: So we can make sure that you don't have strep going on. Okay so rheumatic fever is a complication of
strep. Scarlet fever is a — I don't really want to call it a complication, it's really more of manifestation of it. We talked about toxic shock syndrome caused by staph but actually strep can do that, too.
Dr. Michelle: Right.
Dr. Mike Patrick: So I guess that's another potential complication of strep and it looks like Scarlet fever but then you can go into shock, your blood pressure drops and bad things happen with that, but fortunately that's pretty rare. And then what about the kidneys? How can strep affect the kidneys?
Dr. Michelle:& You can develop acute glomerulonephritis. That's a big fancy term meaning problems with your
kidneys. Unfortunately, this can occur even when we treat strep throat. Even if we treat it, they can end up with
kidney complications. The good thing about that is usually, again, self limiting. So there's usually not long-term
damage from this but approximately 10% of people with strep throat can develop the glomerulonephritis. Even more can with the skin infection. And it usually occurs about 2 weeks after the acute infection and mild manifestations are going to be microscopic hematuria, which means when we look at your urine under a microscope we can see some red blood cells. But more severe manifestations can be–
You can actually see blood in your urine. You can leak protein because your kidneys– the basement membrane isn't working properly so protein can escape where it's not suppose to. You can even develop swelling, high-blood
pressure and in worst case scenarios, renal failure.
Dr. Mike Patrick: I've never seen renal failure with it but in the last 10 years, I have had a few kids with elevated blood
pressure and quite a bit of edema, swelling of the soft tissues especially around the feet and ankles. I mean, it's
definitely a scary thing when it gets that bad but most everybody recovers from this.
Dr. Michelle: And fortunately most of them recover within a month. So it's not terribly long.
Dr. Mike Patrick: And then, one other thing in the outline that you had sent to me regarding this talk. PANDAS which is the
pediatric autoimmune neuropsychiatric disorder associated with group A strep, we can probably skip that because we did discuss that way back in Pediacast episode number 35, and we talked about hat a little bit then.
So if you are interested in that, this is sort of a behavioral type disorder. Actually it can mimic the autism spectrum
disorders and sometimes kids almost seems like they are becoming autistic, you know, sort of one of the mild one
to the mild form of autism in this spectrum, but really, it's just this following of group A strep infection. So it's kind of
interesting but we did talk about that a lot in Pediacast 35.
Dr. Michelle: In response to our listener question if I'm not mistaken.
Dr. Mike Patrick: Yes, that's right and so we'll put a link in the show notes to that episode, so you can find out all about it. So
this would be all of the autoimmune type complications of strep. What about infection complications from the
bacteria itself? What can go wrong with strep there?
Dr. Michelle: Right. Well a majority of them would go away on their own without treatment. You can develop
worsening infection from it. You can get a cellulitis in the back of your throat. Or even an abscess which is a
clumped area of infection that needs to be drained. So often caught peritonsilar or retropharyngeal space
abscesses and in order to get rid of it, you have to stick a needle in there and drain the infectious material out.
Dr. Mike Patrick: Right, and this is a bad space too because the airway is right there.
Dr. Michelle: Right.
Dr. Mike Patrick: So this is not a kind of abscess you really want.
Dr. Michelle: Among the abscesses that I would choose, this would not be one of them.
Dr. Mike Patrick: Right, right.
Dr. Mike Patrick: If you had to choose an abscess, you don't want it around your tonsils.
Dr. Michelle: And nor do I want a needle going in there if I can avoid it.
Dr. Mike Patrick: Right.
Dr. Michelle: You can also get ear infections — otitis; you can get mastoiditis, which is there's a bone right behind
your ear, if you push right behind you ear, you can feel a bone there. You can get an infection of that. That can
spread further and give you a meningitis or infection in the brain or the area surrounding the brain. You can get
sinusitis because, I mean, again, direct extension right into the sinuses.& That one's probably one of the most
common ones. You can get pneumonia, osteomyelitis or septic arthritis, which is infection to the joints or into the
bones. Worst case, in terms of infection is probably bacteremia or a sepsis. So it seeps into your bloodstream and that can cause some pretty bad complications as well.
Dr. Mike Patrick: And this would be Jim Henson. He's sort of the– That's how he died. Isn't it?
Dr. Michelle: You are asking the wrong person. I have no idea.
Dr. Mike Patrick: Oh you know, the Muppet guy. You know who I'm talking about.
Dr. Michelle: I do know who Jim Henson is. I'm sorry I don't know how he died.
Dr. Mike Patrick: Yes, he died from– He had pneumonia from– He had strep throat and then developed a pneumonia and
than bacteremia and then went into shock and died. It's true.
Dr. Michelle: Well, I just learned something new. Thank you!
Dr. Mike Patrick: Yes, yes, yes.
Dr. Mike Patrick: Actually, in our community where I practiced a couple of years ago, there was a high school principal who
also had sore throat for a couple of weeks, didn't go to the doctor's and got pneumonia, didn't go to the doctor's and
eventually he, actually died too. He had strep bacteremia as well.
So it can be bad, and I guess when you– This is so complicated. This has really been sort of a high intensity
Pediacast in terms of the science a little bit. And it just shows you, I mean, and this is why you want to trust
your doctor and not try to diagnose these things at home because there's so many little issues that you don't see
very often but we have to always think about.
Dr. Michelle: Absolutely. All these things cross our mind when these patients come in.
Dr. Mike Patrick: Right. Well, thank you very much, Dr. Michelle, for joining us–
Dr. Michelle: Of course.
Dr. Mike Patrick: And enlightening us on strep throat and Scarlet fever and rheumatic fever, we threw that in there
too. Next time that you come, next month we're going to talk about the third disease. Right? Third?
Dr. Michelle: Rubella. That is what we're on. Third disease.
Dr. Mike Patrick: Okay. That one, you know, there's not quite as much to say about that one, but it'll still be an interesting
Dr. Michelle: [Laughs] Here's hoping.
Dr. Mike Patrick: [Laughs] That's right.
Dr. Mike Patrick: Did you have a nice Christmas.
Dr. Michelle: I did, except I was working. So I was in the hospital for both Christmas and New Year's but it wasn't as
bad as it could have been.
Dr. Mike Patrick: For both?
Dr. Michelle: I was on for both, yes.
Dr. Mike Patrick: You didn't get a break with one of them?
Dr. Michelle: No, bummer.
Dr. Mike Patrick: Do you guys a different schedule around the holidays? I remember when I was a resident for those two
weeks around Christmas and New Year's, we kind of went in to a different mode so that you work several– like I
think it was 12 on, 12 off for three or four days and then you were off for three or four days.
Dr. Michelle: No not really. We're kind of in our status quo, so I was on in-patient, meaning I was seeing all the
patients in the hospital, so you still have to go in. We have a holiday call person so our normal call person didn't
have to stay in the hospital overnight for both holidays, but I still had to go in and around and see all the patients.
Dr. Mike Patrick: So you are in Hawaii for the holidays, and you have to work.
Dr. Michelle: I know, what a bummer!
Dr. Mike Patrick: I mean you know, being in Hawaii, everybody wants to go there to vacation, and I'm sure you're not really
excited about it or are you?
Dr. Michelle: You know, it is a good place but honestly, I can count both hands the number of times I've had the
opportunity to go to the beach during residency.
Dr. Mike Patrick: Right, right. It's not a vacation at any stretch.
Dr. Michelle: But I have to sign that I'll be staying here when I graduate, so–
Dr. Mike Patrick: Oh, is that right?
Dr. Michelle: Hopefully I'll have more time. Yes! In fact, I have exciting news. I will be opening a group practice on an outer island with some of my co-workers now, we'll be opening our own practice.
Dr. Mike Patrick: That is great, that is great. Congratulations on that.
Dr. Michelle: Oh thank you.
Dr. Mike Patrick: So is this a small town?
Dr. Michelle: It will be. We're going to go to the big island of Hawaii, because before I moved here, I had no idea
that the islands all had different names and everything. I was completely ignorant of Hawaii. But I'm on Oahu right
now which is where Honolulu is, but the biggest island is the called the Island of Hawaii or the Big Island, and I'll be
working in a small town called Hilo.
Dr. Mike Patrick: Excellent. Do they have a family practice there now, or is this something–
Dr. Michelle: They have a shortage of physicians out there right now and they're kind of in a crisis. They do have
several family medicine docs.
They have a couple of pediatricians, a couple of OBs. I think there are two surgeons. They have a hospital and
everything but they have a lot of patients who don't have access to doctors because there's just not enough doctors
to go around.
Dr. Mike Patrick: Well, that's great. It's just fantastic that you're doing that and are able to.
Dr. Michelle: I'm sort of excited.
Dr. Mike Patrick: Yes. You have internet access and all that–
Dr. Michelle: Of course, yes. It's not that rural. [Laughs]
Dr. Mike Patrick: You know, my wife and I have talked about that before. It's like, take away anything but please, don't take
away the internet.
Dr. Mike Patrick: It's kind of sad, but it's true.
Dr. Michelle: We can't function today without it.
Dr. Mike Patrick: Yes, in fact we know– It's sort of one of these roundabout things — we know some people who knows
someone who lives in Alaska in Barrows, Alaska which is like as north as you can go and they do have internet, but then I said, you know, internet and heat and I guess food too, but …
Dr. Mike Patrick: But we don't have much else up there either.
Dr. Michelle: No, when you get more though, the connections can be a little questionable sometimes.
Dr. Mike Patrick: Yes, yes. Alright. We're going to wrap things up. Thanks again for stopping by and we'll look forward to
seeing you next month.
Dr. Michelle: Sounds great. Thanks so much, Dr. Mike.
Dr. Mike Patrick: Alright as always, thanks go out to Nationwide Children's Hospital for providing the bandwidth for the
show. Also Vlad, over at vladstudio.com for providing the artwork for the website and the feed.
Thanks to Dr. Michelle for taking time out of her very busy schedule to stop by and share some information with us
about Scarlet fever and of course, as always, a great big thank you to all of you for joining us and participating in the show. Pediascribe, the blog — Karen did a post called Saturday photohunt important. It's a tradition in the
blogosphere. Each Saturday there's a topic and lots and lots of bloggers find a personal photo from their family or
from their life or experiences related to the topic at hand and of course there's lots of individual interpretations of the topic, and last Saturday's topic was "important."
Karen's take on this is that people, relationships' love is important and she tells a story of a family that we're friends with that we have vacationed with in the past — in fact, of course that takes a special friendship to vacation with someone.
It was a picture taken at Disney World, and unfortunately it was that family's last vacation together. The dad died
from an unknown heart condition just a few months later. So, Karen talks about that, check out the picture and
Karen's take on the word "important," and of course you'll find a link to that in the show notes at pediacast.org.
Alright, don't forget, okay I'm going to go through it real quick. iTunes reviews, if you haven't done that, please do. Also, the poster page is available at the website and of course word of mouth always helps to spread the word about the program. So, everybody, have a great weekend. We are going to get to some Skype calls next week. So if you recently called the Skype line and had a question, we're going to get to that after the weekend and until then, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody!