5-100
Continuation of acute signs, red/swollen area spreads locally, color turns to blue/purple with bullae, may see
gangrene by day 4-5. Chronic (>7 days): Earlier signs continue, clear demarcation at site of involvement
Palpation: Acute (< 24 hr): Tenderness >inflammatory change, area warm to touch; may see capillary leak
syndrome with generalized edema (the “Michelin man” look), in myositis find changes c/w compartment
syndrome of affected area. Sub-acute/Chronic: Continuation of earlier signs, other physical findings related
to multi-organ system failure in severe cases (see Respiratory: ARDS)
Using Advanced Skills: Lab: Gram stain of fluid or tissue (blood, throat, wound and debrided tissue) for
gram-positive cocci in chains (see Color Plates Picture 26). CXR to assess for early ARDS development.
Assessment:
Differential Diagnosis:
Necrotizing fasciitis - due to Clostridia; crepitus on physical exam or gas on X-ray.
Cellulitis or lymphangitis - deep streptococcal infection is much more painful and purpuric.
ARDS or multi-organ failure due to other cause - see Respiratory: ARDS
Plan:
Treatment
- If suspect diagnosis, evacuate immediately for surgical and intensive care support.
- If evacuation is delayed or not possible, give antibiotics. IV Penicillin 24 MU/day (4 MU q 4 hrs)
and Clindamycin 900 mg q 8 hrs for 10-14 days. Clindamycin decreases streptococcal toxin production.
Intravenous immunoglobulin (IVIG) 150 mg/kg/day for 5 days given early may decrease mortality. - Aggressively debride deep-seated infection. External findings are often the “tip of the iceberg” regarding
tissue involvement. (see Procedure: Wound Debridement) - Oxygen, IV fluids (LR or NS) and other treatment as in ARDS section. Consider adding ceftriaxone or
ciprofloxacin.
Patient Education
General: The infection control recommendation for this is contact isolation and if in the lungs respiratory
droplet precautions.
Prevention: Secondary cases are rare but consider streptococcal prophylaxis (Pen VK 250 mg po qid) of
close contacts.
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate suspected cases immediately. Consult infectious disease
specialist early.
Zoonotic Disease Considerations
Agent: Group A Streptococcus spp
Principal Animal Hosts: Cattle, swine, and horses
Clinical Disease in Animals: Meningitis and arthritis in swine; mastitis in cattle and horses; respiratory
disease and strangles in horses
Probable Mode of Transmission: Direct contact; ingestion of raw milk
Known Distribution: Worldwide
ID: Tetanus
COL Naomi Aronson, MC, USAIntroduction: Clostridium tetani bacteria are introduced into the body through contaminated open wounds,
burns, frostbite, needles, or unclean cutting/dressing of the umbilical cord. The tetanus toxin (tetanospasmin)
causes acute central nervous system intoxication. Case fatality rate is 10-90%. The incubation period is
3-30 days, depending on the dose and the distance of inoculation from the central nervous system. About
one million cases per year occur worldwide, especially in tropical and developing countries (50% cases are