You see a 6-year-old male who has had a sore throat since yesterday. He has not had a fever and is currently afebrile. He complains of a slight runny nose and headache. On examination you note a tonsillar exudate and anterior cervical lymphadenopathy. A rapid antigen detection test for group A beta-hemolytic streptococci is negative.
The most appropriate course of action at this point is to:
Correct Answer B:
A rapid antigen detection test (RADT) was performed in this patient because he exhibited two criteria for streptococcal pharyngitis. In children and adolescents, a backup throat culture is still recommended because the sensitivity of the RADT is only in the 80%-90% range. Guidelines do not recommend empiric treatment for pediatric patients, but do recommend bacteriologic confirmation of group A beta-hemolytic streptococcal pharyngitis by rapid antigen detection testing or throat culture prior to initiation of treatment.
A 7-year-old male presents with a fever of 38.5°C (101.3°F), a sore throat, tonsillar swelling, and tender anterior cervical adenopathy. He does not have a cough or a runny nose. His younger sister was treated for streptococcal pharyngitis last week and his mother would like him to be treated for streptococcal infection.
Which one of the following is true concerning this situation?
Correct Answer A:
The patient has a score of 5 under the Modified Centor scoring system for management of sore throat. Patients with a score of 4 and 5 are at highest risk (at least 50%) of having group A beta-hemolytic streptococcal (GABHS) pharyngitis, and empiric treatment with antibiotics is warranted. Various national and international organizations disagree about the best way to manage pharyngitis, with no consensus as to when or how to test for GABHS and who should receive treatment. The minimal benefit seen with tonsillectomy in reducing the incidence of recurrent GABHS pharyngitis does not justify the risks or cost of surgery. Treatment of pets for the prevention of GABHS infection has proven ineffective.
Centor Criteria - The patients get one point for each positive criterion:
The Modified Centor Criteria add the patient's age to the criteria:
A 36-year-old man has a 4-week history of a generalized, intensely pruritic papular rash. He is otherwise well. His 9-year-old son also has itching. On examination, there is a generalized rash consisting of excoriated papules and vesicles on wrists, sides of fingers, arms and buttocks. No other abnormalities are noted.
Which one of the following is the most likely diagnosis?
Correct Answer C:
Scabies is an infestation of the skin with the mite Sarcoptes scabiei. Scabies causes intensely pruritic lesions with erythematous papules and burrows in web spaces, wrists, waistline, and genitals. Diagnosis is based on examination and scrapings. Treatment is with topical scabicides such as permethrin.
A 3-month-old infant is brought to your office with small pustules on the soles of the feet and a few similar lesions on the palms of her hands.
Scabies is identified in scrapings of the lesions. You should:
Scabies is usually not seen on the head, neck, palms, and soles in adults, but these areas are often affected in infants.
5% permethrin cream is the most common treatment for scabies. It is safe for children as young as 1 month old and women who are pregnant.
→ Lindane may be hazardous to young infants because of its percutaneous absorption and potential neurotoxicity.
→ Crotamiton cream and sulphur in petrolatum are safe options, but must be applied continuously over 3.5 days.
→ Laundering of clothing and bedclothes is sufficient to prevent reinfestation. In fact, clothes may simply be hung outside for 3-4 days, because the isolated mite dies within 2-3 days.
The most appropriate initial treatment for scabies in an 8-year-old male is:
5% permethrin cream is the drug of choice for scabies treatment, especially in infants over age 2 months and small children. It is more effective than crotamiton in treating symptoms and reducing chances of secondary bacterial infection. This agent is highly effective, minimally absorbed, and minimally toxic.
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