World Wide Rise in Scarlet Fever Newly Reported in Lancet Issue. I include also the study of three patients with rapidly fatal pulmonary hemorrhage and pneumonitis also from strep Serotype M1. The association with pulmonary hemorrhage has been seen before and has carried a specific name as a “syndrome” used in prior editions of Tintinalli’s text which is the core content for all emergency physician education. So these case reports are awful but have been seen before in decades past.

Scarlet fever, is a disease that struck fear into the heart of parents back centuries until the advent of antibiotics…when cases surged in the days of long ago.  This strep infection is making an unexpected and new increase in pediatric cases in certain parts of the world.  This is not yet true in the United States.  Read below this excerpt from an article reported last week on Monday in late November 2017.

England and Wales have seen a substantial rise in scarlet fever cases starting in 2014. The number of cases is 3x as from 2013 and continued to increase in 2015 and 2016, with England and Wales last yr recording the highest # of cases there in a half-century!

British scientists reportedMonday in the journal Lancet Infectious Diseases.

Similar even larger sudden increases of pediatric cases of scarlet fever have been reported in recent years in S. Korea, Vietnam, China, and Hong Kong.  Hong Kong, which saw a 10x rise in cases, continues to report increased annual counts 5 years after the resurgence was reconized.

The reason for the sudden increase is a complete mystery as of the report in the Lancet. And the authors of a commentary that accompanied the article urge other countries to be on the lookout for similar spikes in cases.  Here is a quote:

“Scarlet fever epidemics have yet to abate in the U.K. and northeast Asia. Thus, heightened global surveillance for the dissemination of scarlet fever is warranted,” wrote Mark Walker and Stephan Brouwer, of the University of Queensland in Australia.

Scarlet fever is not a reportable disease in the U.S., and the Centers for Disease Control and Prevention does not track the condition. Scientists there are aware of the spike in cases in some jurisdictions, but a spokeswoman said officials have not heard of an increase in the United States.

Scarlet fever is one of a diverse array of conditions caused by infection with the bacterium Streptococcus pyogenes, also known as group A Strep. This bacterium can cause both strep throat & impetigo — the latter is the most common pediatric rash that presents to emergency rooms based on data I have seen in emergency medicine literature …editorial comment DDC.  It is a honey colored, crust-forming skin sore that is easily spread on the same person by scrubbing and is also highly contagious. It can also cause pneumonia and necrotizing fasciitis — also known as “flesh-eating disease”.

Scarlet fever is also known as “scarlatina.” The name is because of the diffuse red rash that is classic of the infection; it is often more palpable than visible.  The rash generally fades after about a week.  It is accompanied by a high fever and often by strep throat. Most commonly Dxed in children, it spreads in the saliva droplets coughed and sneezed by infected individuals.  There is likely a carrier state with no symptoms.  There is for many organisms like staph aureus…DDC.  The author from the reference to the Lancet article continues

“In the 1800s and well into the 1900s, scarlet fever was commonplace. And even into the early years of the 20th century, deaths from the infection were common. Readers of the children’s novel “Little Women” will remember the tragic death of Beth March, who succumbed to scarlet fever — a fate she shared with author Louisa May Alcott’s real-life sister, Elizabeth.

Complications of the infection could be serious as well. Some children went on to develop rheumatic fever, a serious infection that causes heart damage. Other complications affect kidneys and joints.

Scarlet fever is now treated with antibiotics, though even before these drugs were widely available the death toll of the infection fell markedly. By the 1950s deaths from scarlet fever were rare and by the 1980s cases of the disease were as well.

But it never went away entirely. “It’s always been with us,” said Theresa Lamagni, an epidemiologist with Public Health England and first author of the paper. Lamagni noted that in 2013 scarlet fever cases in England and Wales were seen at a rate of about 8 per 100,000 children. That soared to 27 per 100,000 in 2014 and 33 per 100,000 in 2016.

The increase in cases has not led to fatalities, though about 3 percent of infected children have been admitted to hospitals. Most of the stays were short, and in some cases may have been a reflection of parental or physician concern in the face of a previously rare condition, Lamagni said.

In an effort to try to figure out what is causing the sudden rise in cases, she and her co-authors studied bacterial samples from 303 infected patients in 2014. Their theory was that a new and more efficient strain might explain the increase. But they found — as did scientists in South Korea and Hong Kong — that multiple strains had caused the infections.

“The strains didn’t give us the answer. We were really pinning our hopes on those, because that’s the most obvious answer,” she noted. “We’re left thinking what on earth it could be. We don’t have an answer at the moment.”

Even though scarlet fever does not have to be reported to the CDC, Lamagni said a surge in the United States would be hard to miss.

“If they were seeing what we’re seeing, they would know about it. It is unusual,” she said.”

My further comments on this article DDC:  In teens and even adults we often see patients who believe they have a strep throat but often cultures can prove this wrong.  We have a screen in emergency departments that can be performed but sensitivity and specificity of the test is not constant in all sites and vigorous use of a swab is important for this culture…people don’t like this especially pediatric patients.  (It makes them gag).  Parents often want antibiotics no matter how the patient presents.  So many physicians do provide antibiotic coverage.  Some use an approach to treat based on a positive screen.  If the swab screen is negative for strep and they also often test for mono at the same time…they will wait for the strep culture result, call the parents from the ED and have them start antibiotics by a prescription to be filled only if the culture is positive.  This requires that the ED have a system in place to call patients or their caregivers.  ED patients if not believed to have a reliable way of contact are often treated for this reason alone.  This may lead to increased resistant strains over use of decades of antibiotics.  Yet still today most patients are treated with amoxicillin or even just penicillin.  In medical school still it is taught that strep throat is a self-ltd infection that will resolve on its own.  However, we know that it can also attack the heart valves (there are other signs of this but a new heart murmur with fevers, splinter hemorrhages are signs) of anyone infected which sounds pretty scary since that is serious.  So many physicians simply treat.

There are also a nephritogenic strain of group A strep that attacks the kidneys often a month after an infection like strep throat or scarlet fever.  Antibiotics do not seem to affect this group of strep and DO NOT prevent this complication.  ALL EMERGENCY PHYSICIANS SHOULD WARN PARENTS AND PATIENTS OF THIS POTENTIAL COMPLICATION BECAUSE OF THE DELAY IN THE ONSET OF SYMPTOMS AND THE PATIENT MAY NOT MAKE THE ASSOCIATION WITH THE PRIOR STREP INFECTION.  IT CAN LEAD TO RENAL FAILURE.  Anyone with decreased or dark urine, malaise, should be evaluated for this complication.

 

There have been rare cases in adults of post-streptococcal rapidly progressive glomerulonephritis (RPGN).  They present with rapid onset edema, oliguria, hypertension, and hematuria.   These cases are also rarely associated with diffuse pulmonary alveolar hemorrhage.  It is an immune complex disorder in the kidneys and patients are treated with steroids.  It has been called “pulmonary renal syndrome”.  See Sung HY, et al.  J Korean Med Sci.  2007.

Finally there is a form of illness that can cause pulmonary hemorrhage.   It was reported again in an article from the CDC on Emerging Infectious Diseases:  See volume 20, number 1 – January 2014. It is titled: “Rapidly Fatal Hemorrhagic Pneumonia and Group A Streptococcus Serotype M1”:  http://dx.doi.org/10.3201/eid2001.130233.  The authors are:Santagati M, Spanu T, Scillato M, Santangelo R, Cavallaro F, Arena et al.   Here is a pdf of the article of the 3 cases of rapidly fatal hemorrhagic pneumonitis-i.e., this is the link to the pdf article from the  CDC on the 3 cases of rapidly fatal hemorrhagic pneumonitis due to strep infection:  https://wwwnc.cdc.gov/eid/article/20/1/pdfs/13-0233.pdf

 

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