Complications
A suppurative complication resulting from hematogenous spread of the organism (invasive group A streptococcus infection).[2][10][49]
A high index of suspicion and early diagnosis are essential, as serious life-threatening infections can develop within 24-72 hours. Initial signs and symptoms are usually nonspecific (e.g., pain, fever, malaise, and muscle aches). The clinical course is often precipitous, and requires early treatment in an intensive care unit.
Streptococcal toxic shock syndrome is treated with early empiric antibiotic treatment, and further culture-sensitive antibiotics. The addition of intravenous immunoglobulin may be considered, although data on efficacy are conflicting.[55] Early and immediate surgical debridement should be considered in most patients.[55]
A suppurative complication resulting from hematogenous spread of the organism (invasive group A streptococcus [GAS] infection).[2][10][49] Suspect necrotizing fasciitis in a patient with a rapidly progressing soft-tissue infection and any of the following: severe pain (disproportionate to the clinical findings) or anesthesia over the site of infection; edema and erythema (edema will typically extend beyond the erythema); systemic signs of infection.[56]
Necrotizing fasciitis (due to GAS) is a surgical emergency, requiring rapid debridement of the infected subcutaneous tissues, in combination with intravenous antibiotics.[3]
A suppurative complication resulting from hematogenous spread of the organism (invasive group A streptococcus infection).[57]
Consider pneumonia in children with high fever (>102.2°F [>39.0°C]) and/or any of the following signs: tachypnea (respiratory rate >60 breaths per minute ages 0-5 months; >50 breaths per minute ages 6-12 months; >40 breaths per minute ages >12 months), crackles in the chest, nasal flaring, chest indrawing, cyanosis, and oxygen saturation ≤95% when breathing air.[58] Initial treatment of pneumonia is with empiric antibiotics.[59]
A suppurative complication resulting from hematogenous spread of the organism (invasive group A streptococcus infection).[57]
Symptoms in children may be subtle and nonspecific (especially in younger age groups). A low threshold for suspecting sepsis is therefore important. In general, sepsis should be considered in any child with a suspected infection with signs of a systemic response, which may be indicated by a change in vital signs or a change in a child's normal behavior.[60][61] Parental concern about a child's behavior or condition should always be taken into consideration as an important indicator.[61] Initiate sepsis investigations and treatment, including administering empiric antibiotics and fluid resuscitation on suspicion alone.[62] Progression to organ failure and shock is often very rapid, so early recognition and prompt treatment is crucial.
A suppurative complication resulting from hematogenous spread of the organism (invasive group A streptococcus infection).[57]
In children particularly, early signs and symptoms can be nonspecific and similar to other common, less serious illnesses. Classic symptoms of bacterial meningitis include fever, severe headache, neck stiffness, photophobia, altered mental status, nausea or vomiting, and seizures. Diagnosis is confirmed by lumbar puncture. Initial treatment is with empiric antibiotics.[63]
A suppurative complication of scarlet fever that results from local or hematogenous spread of the organism.[2][10][49] Tonsillopharyngeal abscess includes peritonsillar (quinsy) and retropharyngeal abscesses. Suppurative complications tend to occur early in the infection.[49] Symptoms may be nonspecific (e.g., fever, neck pain, dysphagia), especially in children <2 years old. Diagnosis is confirmed by computed tomography scan of neck for retropharyngeal abscess and aspiration or incision and drainage of the swelling for peritonsillar abscess.
Tonsillopharyngeal abscesses are treated with antibiotics. Surgical drainage may be necessary if antibiotics fail.[64]
A suppurative complication resulting from local or hematogenous spread of the organism.[2][10][49] Suppurative complications tend to occur early in the infection.[49]
The first line of treatment is antibiotics targeting group A streptococcus. If antibiotics alone fail, adequate source control by surgical drainage or excision of the affected lymph node, typically by an ear, nose, and throat specialist, may be necessary to facilitate full recovery and prevent additional complications.
Rheumatic fever can occur around 20 days after group A streptococcal pharyngitis and presents as polyarthritis, carditis, subcutaneous nodules, erythema marginatum, and chorea.[47] It is mostly seen between the ages of 5 and 14 years and it is rare in people >30 years old.[54] Symptomatic treatment may shorten the acute inflammatory phase, particularly polyarthritis, which can be very painful. Penicillin is the first-line choice for secondary prophylaxis.[42]
Acute glomerulonephritis is associated with group A streptococcal pharyngitis or skin infection 1-3 weeks after infection. Treating the underlying disorder and managing hypertension, hyperlipidemia, and proteinuria is the mainstay of therapy. Most patients recover without long-term renal impairment. Some patients may eventually need dialysis or transplant.
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