10-month-old boy presents to ED with fever and congestion

James H. Brien

A previously healthy 10-month-old male is taken to the local ED with fever and congestion for 3 days. He is diagnosed with an upper respiratory tract infection, or URI, and treated symptomatically without antimicrobials.

Two days later, the fever and congestion worsen with the onset of a fine, papular, erythematous rash and painful swelling of both feet. He is then admitted to the hospital for further evaluation.

Figure 1. Mucopurulent blood-tinged nasal discharge. Source: James H. Brien, DO

The parents deny any travel, animal or insect exposure, and his immunizations are documented as up to date. On examination, his vital signs included a fever of 103.9 F with tachypnea, tachycardia and a capillary refill of 3 seconds. He is alert but has a decreased appetite. His ENT exam revealed a mucopurulent, somewhat bloody discharge from the nose (Figure 1). He is also found to have swelling and painful erythema of both feet (Figures 2 and 3), and the fine papular rash, like that shown in Figure 4.

Figure 2. Right foot with erythema and swelling. Source: James H. Brien, DO.

Figure 3. Left foot with erythema and swelling. Source: James H. Brien, DO.

Because of possible evolving sepsis, he had a full sepsis workup with a normal CSF but a CBC that revealed a WBC count of 32, and his CRP was 485. The blood culture is growing gram-positive cocci. His respiratory PCR panel is positive for rhinovirus. Because of the scarlatiniform rash, a rapid group A strep screen of the throat and nose are obtained; the throat was negative, but the nose was positive. He then has a nasal culture, which is also growing gram-positive cocci in chains. He has an MRI of both feet, which shows soft tissue swelling and septic arthritis of the first right and second left metatarsophalangeal joints. He is also soon noted to have painful erythematous patches on the volar surface of the left forearm (Figure 5). He is initially treated with vancomycin plus ceftriaxone.

Figure 4. Scarlatiniform rash. Source: James H. Brien, DO.

Figure 5. Painful, erythematous marks on forearm. Source: James H. Brien, DO

Summary:

• A 10-month-old male is admitted with 5 days of URI symptoms and 2 days of worsening fever, scarlatiniform rash, congestion and mucopurulent nasal discharge, with painful, erythematous, swollen feet, and ascending red patches on his left arm, consistent with lymphangitis.
• A rapid strep screen of his throat is negative, but his nose is positive.
• He has a positive blood and nasal culture for gram-positive cocci in chains.
• A respiratory PCR panel is positive for rhinovirus.
• An MRI shows septic arthritis in both feet.

What’s your diagnosis — sepsis with polyarticular septic arthritis and lymphangitis due to which of the following?

A. Streptococcus pyogenes (group A strep)

B. Staphylococcus aureus

C. Kingella kingae

D. Streptococcus pneumoniae

The answer is A, Streptococcus pyogenes, or group A strep (GAS). GAS has been in the news lately with the isolation of a new, more virulent strain (M1_UK), which has nine times more S. pyogenes exotoxin A than other strains. M1_UK caused an outbreak of invasive disease in England and Wales (Lynskey and colleagues). Such was the case here.

 

Figure 6. Two strep cultures from the nose and the throat in the same patient with streptococcosis. Source: James H. Brien, DO

There is an obscure and somewhat poorly defined condition called streptococcosis, involving a URI with GAS, typically in children younger than 3 years of age, resulting in a mucopurulent rhinitis, such as that seen in Figure 1. It may be slowly progressive with lymphadenopathy and weight loss, but it may also present with findings consistent with scarlet fever, depending on the strain. Interestingly, children in this age group rarely have involvement of the tonsils or pharyngeal area. An example of this phenomenon can be seen in Figure 6, a composite of two lab slips showing the culture results of the nose and throat of a patient I saw back in 1986 with streptococcosis and a scarlatiniform rash. The nose culture was positive, while the throat culture was simultaneously negative. Another feature of GAS in younger children is perianal cellulitis (Figure 7). This condition can be a bit more problematic to treat, but generally, one can start by treating as you would for strep throat. That may be all it takes.

Figure 7. Perianal cellulitis due to group A streptococcus. Source: James H. Brien, DO.

The local effects of the rhinovirus infection on the mucous membranes likely set the stage for this organism to breach the barrier and spread through the bloodstream to the feet. The finding of lymphangitis due to GAS is not unusual but is usually proximal to the focus of infection. There was no infection of the hand or arm noted. However, I would not have been surprised to see lymphangitis of either lower extremity. The propensity of GAS to cause lymphangitis was featured in the July 2016 column.

The patient underwent surgical drainage of both feet (Figures 8 and 9) and 3 weeks of IV ceftriaxone followed by 2 more weeks of high-dose amoxicillin. A shorter course may have been sufficient but is usually based on clinical recovery and normalization of the CRP.

Figure 8. Right foot post-op. Source: James H. Brien, DO.

Figure 9. Left foot post-op. Source: James H. Brien, DO.

Kingella kingae is more likely to cause bone and joint infections in children younger than 3 years of age, but the Gram stain should be the clue against that organism, which would be a gram-negative coccobacillus, rather than gram-positive cocci in chains. The Gram stain of S. aureus would appear as gram-positive cocci in clusters. Initial empiric therapy should cover both S. aureus and K. kingae pending culture results. In this case, ceftriaxone was continued for convenience of once-a-day dosing at home until it was time to switch to high-dose oral amoxicillin.

Columnist comments:

I hope you all are finding this new, online version a good substitute for the old print version. Please feel free to email me your thoughts on this or any other topic you would like to discuss. Also, if you have a good case with a publishable picture that you would like to see in this column, just let me know. It is easy and fun.

The Brien family wish you and yours a happy holiday season and a special wish for all those in uniform spending the holidays away from their families. This is always a good time to send a care package. If you don’t know anyone in the military, the U.S. Postal Service is a good place to start. They have special boxes and ideas. Also, the USO and Red Cross are good resources for guidance.

Please keep in touch and let me know how I can improve this column.

Reference:

Lynskey NN, et al. Lancet Infect Dis. 2019;doi:10.1016/S1473-3099(19)30446-3.