5-99
Carditis:
Viral myocarditis - unlikely to see joint symptoms or the E. marginatum rash
Pericarditis - may see diffuse ST segment elevations
Plan:
Treatment
Primary: Benzathine penicillin 1.2 MU IM (600,000 U in children) or oral penicillin 250 mg po qid x 10
days
Salicylates: 4-8 grams aspirin per day x 3-4 weeks
Alternative: Erythromycin x 10 days or azithromycin x 5 days can be used in patients allergic to penicillin.
Other NSAIDs may be used in place of aspirin
Patient Education
General: This can be a relapsing condition.
Activity: Patients with arthritis or carditis should be on bedrest for 2 weeks (up to 8 weeks if cardiac
failure present).
Diet: Regular.
Medications: Expect tinnitus with high dose aspirin.
Follow-up Actions
Secondary prophylaxis with benzathine penicillin 1.2 MU IM q month until age 18, or for 5 years after
acute episode. If carditis/congestive heart failure then use prophylaxis until age 25 or 10 years after last
ARF episode.
ID: Streptococcal Infections
COL Naomi Aronson, MC, USAStreptococcal Pharyngitis and Scarlet fever: see Symptoms: Sore Throat and Pediatric chapter on
CD-ROM
Group B Streptococcal Infection: see Symptom: OB Problems: Preterm Labor
Impetigo and Erysipelas: see Dermatology chapter
Introduction: Streptococci are gram positive bacteria. Some species are pathogenic in humans, responsible
for illnesses ranging in severity from mild upper respiratory infections to life-threatening necrotizing fasciitis.
Fulminant necrotizing fasciitis due to group A streptococcus may begin at a site of trivial trauma (for example
a paper cut, abrasion on a cinder block), with rapid progression over 24-72 hours and 20-70% mortality even
with ICU care. This is a deep-seated, fast moving infection that destroys fascia, fat, muscle and other tissue
but may spare the skin. It often involves the extremities. Streptococcal infection of muscle (myositis) often is
from blood infection, not associated with trauma. It may involve a single muscle group and be associated with
compartment syndrome (see Procedure: Compartment Syndrome Management).
Subjective: Symptoms
Initial flu-like symptoms with fever to 104°F, extreme pain and erythema at infection site.
Focused History: On a scale 1-10, how severe is the pain in the affected area? (Great pain accompanying
mild skin changes suggests a deeper infection.) Have you had any trauma in this area recently? (risk factor)
Have you had any blisters? (suggests a deep tissue infection if no local injury such as frostbite or burns).
Objective: Signs
Inspection: Acute (< 24 hr): Ill-appearing, fever as high as 105oF, SBP <110, increased heart rate,
abrupt onset red/swollen affected area, confusion/mental status changes common. Sub-acute (1-7 days):