An annotated list of ornamentals naturally found infected by Brevipalpus mite-transmitted viruses
The suppurative sequelae of GAS infection may arise via direct bacterial extension or by hematogenous spread, with the structures of the head and neck particularly sensitive to the immediate extension of an otherwise-uncomplicated GAS pharyngitis. Acute otitis media and sinusitis are frequently cited as the most common infectious sequelae of GAS pharyngitis, and both maintain their typical clinical manifestations e.
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Diagnosis, if it occurs at all, may be made by a clinical history of contemporaneous pharyngitis and a positive throat swab. Less common suppurative complications of GAS pharyngitis include peritonsillar cellulitis or abscess and other deep-space neck infections, such as retropharyngeal abscess.
Initial antibiotic choice should include coverage of anaerobes and MRSA. GAS pharyngitis may also extend to cause mastoiditis or bacterial cervical lymphadenitis, and treatment for these conditions should include antibiotic coverage for GAS. It is advisable to remember that GAS pharyngitis might extend to any contiguous space, and there are reports of conditions such as mediastinitis, orbital cellulitis, and brain abscess that originated as GAS pharyngitis. Characteristics and Epidemiology. The annual incidence of pediatric invasive GAS in an industrialized nation has been measured to be 1.
Importantly, however, the presence of an underlying condition has been linked to an increased risk of death in cases of invasive GAS. Prior to the antibiotic era, GAS was a major pathogen of neonatal sepsis. However, the role of GAS in neonatal sepsis has declined, and recent reviews of the literature have found few cases of invasive neonatal GAS disease. Still, given the mortality of the condition, care providers should continue to respect the possibility that neonates of any age may suffer from GAS infection, whether obtained by vertical transmission or by postpartum contact with infected family members.
However, it is notable that a large number of these cases were associated with a primary infection of Varicella zoster chickenpox , and such cases have become much less frequent since widespread vaccine use, circa The remaining balance of invasive GAS disease is composed of GAS pneumonia more common after influenza infection , arthritis, meningitis, endocarditis, peritonitis, osteomyelitis, and other rare infections.
Retroperitoneal Venous Diseases
Of all invasive GAS infections, perhaps none is as feared as necrotizing fasciitis, a member of the broader category of necrotizing soft tissue infections. The presence of GAS defines Type II monomicrobial necrotizing fasciitis, a rapidly progressive infection of deep tissues, including the muscle fascia and subcutaneous fat, which often leads to the loss of limb or life.
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Because necrotizing fasciitis is initially a process of the deep tissue, its surface manifestations may be subtle and falsely reassuring. The skin of an affected area may be warm, swollen, and erythematous with indistinct margins, and a hallmark finding on exam is pain that is out of proportion to other exam findings.
Advanced necrotizing fasciitis may display other classic features, such as bullae or crepitus, but it is preferable to identify the disease prior to the appearance of these. When there is suspicion of necrotizing fasciitis, surgical consultation should be obtained, with surgical exploration being the definitive diagnostic modality for this disease. Laboratory and radiographic studies have insufficient sensitivity to exclude the diagnosis of necrotizing fasciitis, though some studies suggest that CT holds promise in this regard.
Pediatric patients with suspected invasive GAS should be admitted to the hospital, and their care will likely require the input of multiple specialists. In specific cases, such as a well-appearing child with lymphadenitis, outpatient management may be considered see Table 1. However, for most children with suspected invasive GAS, inpatient care will be necessary.
Surgical consultation and source control will often be required, as is the case for septic arthritis, necrotizing fasciitis, and retropharyngeal abscess, among other conditions.
Another primary consideration is the stability of the patient: children with septic physiology with or without compromise in end-organ function require intensive care and standard supportive measures, such as aggressive fluid resuscitation. In addition to resuscitative interventions, treatment with antibiotics is of paramount importance.
However, it is not often possible to quickly confirm GAS as the causative agent in a sick child, so initial antibiotic therapy should be broad, including coverage for MRSA, gram negatives, and anaerobic bacteria. Therapy may later be narrowed when cultures prove GAS, so long as the patient is improving. All antibiotics should be delivered intravenously, as the gastrointestinal tract provides slower drug uptake, and the gut may be compromised in a seriously ill child. Expert bodies advise that treatment courses of 2 or more weeks may be necessary for many invasive GAS infections. Apart from the intravenous use of penicillin, overwhelming infections with GAS have shown a better response to antibiotic therapies, which include protein synthesis inhibition such as that provided by the macrolide antibiotic clindamycin.
In both an animal model and a restrospective review of human children with invasive GAS, significantly better outcomes were obtained with clindamycin than with penicillin alone. Clindamycin should not be used in isolation, due to occasional GAS resistance to this drug.
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Scarlet Fever. Scarlet fever is a GAS disease defined by the presence of a suppurative GAS infection in combination with a toxin-mediated, pathognomonic exanthem. Importantly, all of the dramatic cutaneous findings of scarlet fever are caused not by local infection but by circulating bacterial toxins: one or more of certain streptococcal toxins, termed streptococcal pyrogenic exotoxin A, B, and C, must be present for scarlet fever to occur, and only a subset of GAS strains produce these toxins. In its typical presentation, the rash of scarlet fever begins days after the onset of GAS pharyngitis, although it may rarely follow cutaneous or other GAS infections.
Pruritis is not universal. In flexural and load-bearing parts of the body, the rash may contain linear petechiae, termed "Pastia lines. Though the rash of scarlet fever is not harmful, the disease itself has long been a feared clinical entity, and this is almost certainly due to its epidemiologic characteristics in the s. Before this time, scarlet fever was well-described but not particularly virulent. For unclear reasons, in the early s pandemic scarlet fever began to occur regularly.
The incidence of the disease decreased as well, though not always in lockstep with its virulence, and data from the mid-twentieth century United States show a mortality rate of 0. Toxic Shock Syndrome.
Some GAS infections may become complicated by shock and end-organ dysfunction in a disease termed Streptococcal toxic shock syndrome STSS , an entity whose effects are mediated by bacterial toxins. STSS should not be confused with Staphylococcal toxic shock syndrome, though the two syndromes have much in common. GAS is capable of producing a variety of toxins that lead to STSS, and chief among these are the toxins that act as superantigens.
A superantigen is a toxin that causes the indiscriminate and widespread activation of the host immune system by binding directly to both the T-cell receptor on T cells and the MHC class II molecule on antigen presenting cells. The resulting unregulated activation of the immune system is thought to underlie the shock and organ dysfunction that defines STSS.
Only one study directly examined the effect of IVIG in pediatric STSS, and though it found no benefit, it was restrospective in design and suffered from selection bias. Acute Rheumatic Fever. Acute rheumatic fever ARF is an autoimmune inflammatory sequela of GAS pharyngitis with characteristic clinical manifestations in the brain, joints, skin, and heart. Most common in patients who are years old, ARF has had a sharply decreased presence in industrialized nations since the s, and the World Health Organization estimates its current incidence at 0.
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Accounting for these morbid conditions, ARF has been estimated to underlie at least , deaths worldwide annually. The potential manifestations of ARF are numerous and varied, and the disease is therefore diagnosed by the Jones criteria, a set of five major and four minor criteria, of which two major or one major and two minor criteria must be present to establish the diagnosis see Table 2.
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