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  • Scarlet fever in children and adults with symptoms

    Scarlet fever usually begins with one of the following symptoms: sore throat, vomiting, fever, headache. Within one or two first days, the rash does not appear. It begins with moist warm parts of the body, such as the side parts of the chest, groin, back, on which the child lies. From a distance it appears to consist of identical red spots, but if you look closely, you can see that each spot consists of tiny red dots on the inflamed skin. The rash can capture the entire body and face, but the area around the mouth usually remains pale. The throat blushes, sometimes very much, and after a while the tongue also blushes, first along the edges. When a child has a fever and sore throat, you, of course, should call a doctor.

    Scarlet fever is an acute infectious disease, refers to streptococcal infection caused by hemolytic streptococcus. It is characterized by symptoms of intoxication, sore throat and rashes on the skin.(How to treat scarlet fever folk remedies read here)

    Etiology of scarlet fever.

    The causative agent of scarlet fever - Streptococcus pyogenes( formerly called S. haemolyticus) - β-hemolytic streptococcus of group A, belongs to the genus Streptococcus;Globular or ovoid asporogenic, Gram-positive, chemoorganotrophic facultative-aerobic bacteria of the genus Streptococcus, family. Streptococcaceae. Are arranged in pairs or chains, are motionless. Form the capsule, easily converted into L-form. Hemolytic streptococci are divided into a group-specific polysaccharide into 17 serological groups, which are designated by letters( from A to S).The A group itself, in turn, is divided into 55 serovars depending on the presence of certain type-specific antigens M and T. Contains and produces various substances and toxins( streptolysins, streptokinase, streptodornase, streptococcal DNase, etc.).Common to all serotypes is erythrogenic toxin( thermolabile fraction of Dick toxin).Leading are the 1st, 2nd, 4th, 10th and 27th serovars.

    A distinctive feature of hemolytic streptococcus is the ability to produce hemolytic poison, so that when it grows on media with blood, the latter is hemolyzed. When sowing hemolytic streptococcus on a cup of blood agar 24 hours later, a zone of clarification with a diameter of 2-3 mm appears around its colony.

    Outside the human body, streptococci lasts for a long time. The temperature in 60 ° he can withstand up to 2 hours. Boiling, as well as solutions of 1: 1 500 and 1: 200 mg of carbolic acid, kills streptococcus in 15 minutes.

    The studies on the etiological role of hemolytic streptococcus in scarlet fever and the establishment by the Americans of Dick's toxicogenic ability of scarlatinous races of hemolytic streptococcus started in 1923 by Russian scientist Gabrichevsky significantly advanced our knowledge of scarlet fever. An important result of these studies was the introduction of scarlet treatment methods of specific treatment and prevention.

    Hemolytic streptococcus can be found in mucus throat in the vast majority of scarlet fever patients since the onset of the disease, and later in scarlet fever in local lesions in otitis, mastoiditis, lymphadenitis, arthritis, and in some cases in the blood. Hemolytic streptococcus, isolated from the body of a scarlet fever, develops toxin when grown on liquid nutrient media. Intradermal injection of 0.1-0.2 heavily diluted toxin scarlet fever streptococcus causes at the injection site in persons sensitive to this toxin, 4-6 hours after the injection of redness, which in a day reaches a size of 0.5-3 cm, rarely more. This is Dick's positive reaction. A single skin dose is the minimum amount of toxin, which still gives a clear reaction to sensitive individuals.

    Dick's reaction never causes any general frustration and can be safely applied at any age and in any state of health.

    According to Zinger( USA), Dick's positive reaction was at the age of 0-6 months 44.8%, 6 months -3 years - 65-71%, 3-5 years-56-46%, 5-20 years - 37- 24% and in adults - 18%.These data have been confirmed in other countries. Thus, persons susceptible to scarlet fever, more often give a positive reaction to Dick, whereas in adults and infants with relative immunity, Dick's reaction is in most cases absent. It is usually absent and after the transferred scarlet fever. Obviously, there is a definite relationship between the nature of the reaction of this subject and its susceptibility to scarlet fever, so Dick's reaction is used to determine immunity to scarlet fever.

    A subcutaneous injection, especially of a sensitive child, of large amounts( several thousand doses of skin) of a toxin can cause poisoning phenomena: after 8-20 hours, the temperature rises, a state of frustration arises, a small scarlet scarred rash, a sore throat, vomiting. These symptoms go through 1-2 days, but they clearly prove that the early syndrome of scarlet fever depends on the poisoning of the sick organism with the toxin of hemolytic streptococcus. By immunizing horses with a toxin of scarlet latin hemolytic streptococcus, a therapeutic serum is obtained, which gives a favorable therapeutic effect when applied in the first days of the disease. Treatment of scarlet fever with serum became the practice of most large hospitals. Finally, active immunization of children with a vaccine consisting of bodies killed by scarlet latinous hemolytic streptococci and toxin, increases resistance to scarlet fever.

    Hemolytic streptococcus is sensitive to antibiotics - penicillin, macrolide, tetracycline, etc.

    Epidemiology of scarlet fever. The source of infection is a patient with scarlet fever, a carrier of streptococcus, as well as a patient with streptococcal angina or nasopharyngitis. Scarlet fever is transmitted by airborne droplets. However, it is possible to transmit the infection through contaminated household items, toys, clothing of patients.

    The highest incidence is observed among preschool and early school children. Children under one year of age get scarlet fever very rarely, just as adults rarely get sick. The most common scarlet fever is registered in the autumn-winter period.

    The initial source of infection in scarlet fever is a patient or convalescent, in the throat and nasopharynx of which the causative agent of infection is found. What role in the transfer of scarlet fever is played by healthy people who come into contact with patients, we do not know for sure, but there is no reason to deny the possibility of spreading the infection in this way. The scarlet fever virus enters the external environment with detachable mucous membranes of throat and nasopharynx. It is scattered mainly by a drip. Until recently, it was thought that dermal scales are particularly contagious in case of scarring of scarlet fever patients. But now there are enough reasons to believe that the epithelium, which disappears during peeling, contains the causative agent of scarlet fever only if the skin of the patient - the carrier of the scarlet fever virus - is contaminated with the detachable mucous membranes of its throat or nasopharynx, which practically, of course, almost always occurs. Infection of another person through the sloughing of convalescent can occur only in the event that the scales fall into the mouth of this person. The patient with scarlet fever becomes contagious from the onset of the disease. An infectious patient remains in the period of convalescence. Most convalescents become not dangerous to others in 35-40 days from the swing of the disease. The mandatory term for isolating scarlet fever patients is 40 days. Reconvalvesent with complications in the form of angina, purulent inflammation of the middle ear, suppuration of glands, etc. are a danger to others for a longer time. Especially dangerous are convalescents with inflammatory phenomena in throat and nasopharynx( tonsillitis, runny nose).

    The convalescence of the convalescent increases, undoubtedly, if it comes into contact with scarlatinous patients in the midst of the disease. This is due to the fact that the convalescence, already free from carrier, can again become infected from the patients surrounding it. If fresh patients are placed in the convalescent ward, the convalescents again become carriers of the infection.

    On the contrary, scarlet fever convalescents become non-contagious to others under the following conditions:

    1) hygienic maintenance, individual care and thorough conduct of current disinfection in hospital wards;

    2) isolation in small rooms for 3-4 beds, which limits to a minimum the contact with other patients;

    3) stay convalescent in good weather on open terraces or strengthen ventilation of chambers( opening in good weather windows);

    4) individual isolation for 12 days at home after discharge from hospital and use of fresh air. The latter rule should be widely applied to all discharged from scarlet fever departments;

    5) sanation of throat and nasopharynx by irrigation with penicillin solution( 2 000 IU per 1 cm3);it is better to alternate it with other antibiotics( gramicidin).

    The causative agent of scarlet fever in the external environment. Subjects used by patients, especially underwear, bedding, toys, books of a scarlet fever child, and the room where the patient was, can for a long time serve as a source of infection.

    Some foods, mainly contaminated with scarlet fever milk, can be a source of scarlet fever.

    However, the role of contaminated objects is negligible in comparison with the role of a sick person and convalescent.

    Pathogenesis and pathomorphology of scarlet fever .Infection most often( 97%) enters the body through the tonsils, less often( 1.5%) through the damaged skin or mucous membranes of the uterus( extraphariforme form of scarlet fever).Probably( up to 1%) hit the pathogen through the lungs. In the development of scarlet fever, there are 3 lines of pathogenesis: septic, toxic and allergic.

    When getting on mucous or damaged skin, beta-hemolytic streptococcus causes inflammatory and necrotic changes at the site of implantation. On the lymphatic and blood vessels the pathogen penetrates into the regional lymph nodes, causing purulent inflammation. Otitis, mastoiditis, adenophlegmons, inflammation of the paranasal sinuses and other purulent complications are septic manifestations of scarlet fever.

    The toxin of hemolytic streptococcus, penetrating into the blood and having a tropism for the vegetovascular, neuro-endocrine apparatus, causes symptoms of general intoxication, damage to the central and autonomic nervous systems.

    As a result of the circulation and decomposition of beta-hemolytic streptococcus, the sensitivity of the organism to the protein component of the microbe increases and an infectious allergy develops clinically manifested in the form of an allergic rash, complications( pseudorecidia, nephritis, arthralgia, etc.).

    In the place of primary fixation of the causative agent of scarlet fever, there is a squashing of the epithelium, a cluster of streptococci, zones of necrobiosis and necrosis, which extend into the interior. In the regional lymph nodes, necrosis, edema, fibrinous effusion, and myeloid metaplasia are also found. With septic form, purulent and necrotic foci are localized in various organs and tissues. In the myocardium there are dystrophic changes, in the liver - fatty degeneration. In the brain - acute swelling and severe circulatory disorders.

    Clinical classification of scarlet fever. At present, the classification of scarlet fever, proposed by N.I.Nisevich, V.F.Uchaykin( 1990).

    1. In form:

    • typical;

    • atypical:

    a) erased( without rash);B) forms with aggravated symptoms( hypertoxic, hemorrhagic);

    c) extrapharyngeal( extra-buccal), abortive.

    2. In severity:

    • light, moving to medium severity;

    • medium-heavy, passing to heavy;

    • heavy - toxic, septic, toxic-septic.

    3. On the course of the disease:

    • acute;

    • protracted;

    • without allergic waves and complications;

    • with allergic waves and complications.

    4. By nature of complications:

    • allergic( nephritis, myocarditis, synovitis, reactive lymphadenitis, etc.);

    • purulent;

    • septicopyemia;

    • mixed infection.

    The main clinical manifestations of scarlet fever: acute onset, increased body temperature to high numbers, symptoms of intoxication, sore throat( angina), regional lymphadenitis and the appearance of rash by the end of the first or second day of the disease.

    Symptoms. The incubation period for scarlet fever lasts on average 3-7 days, less often it stretches to 12 days. In some cases, it may, apparently, be shortened to a day. Sometimes during incubation, children complain of fatigue, lack of appetite, headache. In the majority of cases, pronounced prodromal phenomena do not occur, and the disease manifests itself suddenly with a more or less severe chill or slight cognition. There is vomiting. The temperature within the first 12 hours reaches high figures( 39-40 °).Ill children look seriously ill and complain of general weakness, heat, heaviness and pain in the limbs, sacrum, headache, dry mouth. Swallowing is painful. The sleep is disturbed, at night the patient is delirious. Already in this period, a frequent pulse is found, limited to the bright red of the soft palate, tongue and tonsils. Submandibular lymphatic glands are painful when palpated. The tongue is coated with a greyish-white coating. The face is puffy. The cheeks are feverishly red. During the first day, rarely on the 3-4th day after the onset of the disease, a characteristic scarlet fever appears, consisting of individual bright red small-dotted elements merging into a continuous red. The rash begins with the neck and upper chest and for 2-4 days spreads throughout the body. The face of the scarlet fever patient during this period has an extremely characteristic appearance due to the bright red cheeks and contrasting with the white triangular portion of the chin and the circumference of the mouth( Filatov).Following the rash, the temperature rises slightly and lasts for several days on high figures. In uncomplicated cases, along with blanching of the rash, the temperature also falls, reaching the norm by the 9th-12th day. At the height of the disease, the pulse is accelerated, the common phenomena of intoxication and local phenomena in the throat are amplified. On the tonsils appears dirty white or yellow-white coating, which can spread to the soft palate and tongue. The tongue is gradually released from the plaque and takes on the 4-5th day of the disease, due to the enlarged papillae, a characteristic bright red, crimson color. The submaxillary glands are enlarged along with the growth of the lesion in the throat;sometimes the occipital lymph glands are involved in the process.

    On the part of the blood in the first days of the disease, neutrophilic leukocytes are noted. From the 3rd-4th day, there is zosinophilia. In the absence of complications and favorable flow of blood to the 7-10th day comes to normal. With purulent complications, leukocytosis is again observed.

    Along with the disappearance of the rash and the drop in temperature, the phenomena from the side of the pharynx gradually decrease. On the skin appears first scaly, and on the 3-4th week - lamellar, extremely characteristic, especially on the palms of the hands and on the soles of the feet, peeling.

    Peeling is an important symptom that is rarely absent even in mild cases and often gives the opportunity to establish a late diagnosis of scarlet fever.

    Questions of the pathogenesis of scarlet fever have been thoroughly studied by Soviet scientists( Kisel, Koltypin, Molchanov).

    During the scarlet fever, it is necessary to distinguish the first period of the disease( sore throat, rash, intoxication and fever), followed by a period of relative well-being until the 3rd week, and the second period, from the 15-20th day, when typical complications develop: lymphadenitis, nephritis, otitis, etc. In the second period, a scarlet latin patient appears to have a special sensitivity to streptococcus, which affects the frequency and nature of the complications.

    Depending on the severity of the epidemic, the massive infection, the virulence and pathogenicity of this strain, the degree of immunity of the infected infection, or manifests itself in the form of the described moderate-severe disease, or can give all the transitions from lightning-fast to light, erased forms.

    It is almost customary to distinguish scarlet fever from mild, moderate and severe, or, as many designate, scarlet fever I, II and III.With a light scarlet fever, the first period of the disease proceeds more gently. Consciousness is preserved. Vomiting is single or absent. The general condition is satisfactory. Pulse full, moderate frequency. The febrile period lasts 5-6 days;the temperature can be kept within 38-39 ° or even lower. Angina is mostly catarrhal, there are no necrosis( raids) in the throat, or they have a point character. The cervical glands are little involved in the process, there is only a slight increase in tonsillar glands. The rash may be typical or poorly expressed, sometimes it is only on the chest, neck, in the groin.

    Complications in mild form occur in the form of nephritis and non-nasal lymphadenitis.

    The erased forms of scarlet fever manifest themselves in the form of catarrhal sore throat, subfebrile temperature and minor common disorders. The rash may or may not be present at all or a pale, lean, soon-passing exanthema, which nevertheless usually causes typical peeling of the skin in convalescents. These erased forms, often observed in adults, older children, infants and vaccinated children, have immense epidemiological significance, since they can easily be viewed and become long-lasting sources of infection for others.

    A typical medium-heavy form of scarlet fever produces significantly more complications and among them purulent( otitis, mastoiditis, lymphadenitis, etc.), the outcome of which can sometimes be sepsis.

    The most dangerous is severe scarlet fever( scarlet fever III), which can manifest as a toxic, septic and mixed toxic-septic form.

    Toxic form of scarlet fever begins with a sudden high temperature( up to 40 ° and above), repeated vomiting, often diarrhea. Consciousness is darkened, there can be convulsions. The rash is plentiful, sometimes with a cyanotic hue or a hemorrhagic nature. Pulse is frequent, weak, blood pressure is lowered. The pupils are narrowed, the eyes are red. From the side of the throat changes can be limited to catarrhal angina. After 1-3 days the patient can die with the phenomena of general intoxication and rapidly developing cardiovascular weakness.

    The septic form of scarlet fever does not give the first 1-2 days of terrible phenomena of general intoxication. There are deep lesions from the throat in the form of necrotic sore throat and necrotic processes in the nasopharynx. Tonsils are greatly enlarged, covered with a vast dirty white coating. There is a bad smell from the mouth, a mucopurulent discharge from the nose. The child breathes with difficulty, opening his mouth. The upper part of the face is edematous due to inflammatory processes in the frontal and latticular sinuses. Submandibular and cervical lymphatic glands are greatly enlarged, painful. Sometimes subcutaneous tissue is involved in the inflammatory and necrotic process;then there is a dense, purple-colored swollen neck tumor( adenophlegmon).In these cases, the child's death quickly occurs. In septic scarlet fever, as a rule, numerous streptococcal purulent complications from the ears, subordinate cavities, joints, heart damage, kidneys, purulent pleurisy often occur, and the case often results in general sepsis and death of the child.

    In practice, it is often necessary to meet mixed, or toxic-sentic forms.

    A peculiar form - extra-buccal scarlet fever - is sometimes observed( more often in children than in adults) after burns and other injuries with violation of the integrity of the skin or mucous membranes. With this form, the rash first appears around the place of injury. This form should be remembered as a possible source of infection, especially in children's surgical departments.

    In severe forms of scarlet fever, the rash may not only be small-spot, but spotty-papular or hemorrhagic, and have a cyanotic appearance. Usually the rash lasts 3-7 days, and then disappears without leaving pigmentation. After its disappearance, peeling of the skin from the small pancreas in the neck, ear lobes to the large-plate on the palms, fingers and toes is observed.

    In the first days of the disease, the children have a pronounced lagging of the tongue with a thick gray-yellow coating. Starting from the 3rd-4th day of the disease, the mucous membrane gradually clears from the edges and the tip of the tongue from the plaque, as a result of which the hypertrophic papillary layer is exposed. The tongue becomes bright red, which makes it look like a raspberry berry( a symptom of a "crimson tongue").This symptom lasts for 1-2 weeks.

    Toxins of beta-hemolytic streptococcus specifically affect the autonomic nervous system, which is manifested by an increase in the tone of the sympathetic nervous system in the first 7 days of the disease( sympathetic phase), followed by a change in the tone of the parasympathetic system at the second week of the disease( vagus phase).One of the clinical manifestations of increasing the tone of the autonomic nervous system is a symptom - "white dermographism", resulting from a spasm or paralytic condition of peripheral vessels.

    Changes in the heart with scarlet fever develop most often at week 2 of the disease and are characterized by a slight widening of the boundaries of relative dullness of the heart to the left, the appearance of impurities or systolic murmur on the apex and 5th point, a tendency to bradycardia. In-depth study reveals extracardiac causes( toxic effect on the conductor system of the heart), in favor of which indicates the rapid disappearance of clinical symptoms at the end of the "vagus phase."With the continued preservation of this symptomatology( 3-4 weeks), one can take infectious myocarditis as a complication of scarlet fever.

    The most frequent complications of scarlet fever are lymphadenitis, otitis, sinusitis, mastoiditis, nephritis. In the genesis of complications, the main role is played by two factors: allergy and secondary streptococcal infection, so the most common complications in scarlet fever occur at the 2nd-3rd week from the onset of the disease.

    Allergic complications of scarlet fever develop on the 2-4th week of the disease in the form of simple lymphadenitis, nephritis, synovitis, and allergic waves. This is manifested by intoxication, increased body temperature to febrile digits and the appearance of a rash of a different nature, mainly localized on the extensor surfaces.

    Complications of severe forms of scarlet fever develop already at the beginning of the disease, usually occur in certain periods of the disease. Since the end of the first week of the illness there are disorders of the cardiovascular system: a slight extension of the heart to the left, systolic noise at the apex, slowing of the pulse, arrhythmia, a drop in blood pressure, an increase in the liver. Seldom there are edemas. In mild cases, there may be a slight slowing of the pulse and arrhythmia. These phenomena occur at the third week of the disease and are called "scarlet fever heart."The main cause of these complications are disorders of the autonomic nervous system( oppression of the sympathetic nervous system and adrenal glands producing adrenaline).

    Beginning at the end of the 2nd week and at the beginning of the 3rd, complications typical of scarlet fever appear: jade, otitis, lymphadenitis, mastoiditis, arthritis.

    Scarlet fever is manifested after the passage of acute phenomena. Without apparent reasons, the child becomes pale, sluggish, good before that appetite disappears, the temperature reaches 38 ° and above, the face becomes puffy, nausea and vomiting attach. Urine is small, it is dark, reminiscent of meat slops color. In the urine - protein, cylinders, erythrocytes.

    Determine the presence of protein in the urine can be by boiling it with acetic acid. In a test tube pour 5 cm3 of clear( filtered) urine, add 3-5 drops of acetic acid and heat to boiling. When the protein is present, the urine becomes turbid, and a white flocculent precipitate falls out of it.

    Blood pressure is raised to 140-180 mm( with a norm in children 3-7 years in 100 mm, and in older children - up to 115 mm).In severe cases, edema increases, the amount of urine drops to 200 cm3 per day or anuria appears( lack of urine), persistent headache, nausea, vomiting, and it can reach uremia. Uremia rarely occurs suddenly. Uremic attack is expressed in unconsciousness and convulsions. Seizures can last for hours and reappear. With proper treatment, uremia ends safely. In mild cases, all phenomena of jade are limited to a decrease in the amount of urine, the appearance in the urine of protein, a small number of cylinders, red blood cells, and the process ends in a week. There are cases of jade lasting up to 2-3 months. The usual outcome of scarlet fever is complete recovery. Less often the disease passes into a chronic form or the patient dies from uremia, swelling or acceding pneumonia, erysipelas, empyema, etc. The incidence of nephritis in scarlet latin patients varies during different epidemics from 5 to 20%.

    Symptoms of kidney damage( protein, hyaline cylinders in urine) appearing in the first days of scarlet fever are a consequence of intoxication and disappear with the end of the acute period of the disease. In the presence of septic complications, septic nephritis may occur.

    Purulent inflammation of the middle ear( otitis media purulenta) appears with septic scarlet fever at the onset of the disease, usually in the second stage of scarlet fever at the 2nd-4th week. Otitis begins with an increase in temperature. When the pressure on the tragus is pain( not always!).After paracentesis or spontaneous perforation, these phenomena subsided. Suppuration from the ear lasts up to 1-2 months. In mild cases, the tympanic membrane closes and the hearing is fully restored. In severe cases, due to the complete destruction of the auditory ossicles, a severe decrease in hearing is observed, or, more rarely, permanent deafness is established when the inner ear is damaged.

    With mastoiditis( inflammation of the mastoid process), the temperature acquires a remitting nature, the mastoid process is painful when pressed, and later there is swelling behind the ear. In the blood-leukocytosis. The process can spread to the venous sinus and then to the meninges and lead to meningitis, brain abscess, sepsis.

    Sometimes, local phenomena from the side of the mastoid process are not very pronounced, and in the presence of otitis, one must think of mastoiditis with continuing remittent temperature and deterioration of the general condition, which can not be explained otherwise.

    Lymphadenitis in scarlet fever, as a rule, occurs at the onset of the disease in the presence of angina or appears on the 2nd-4th week, often in a period of complete well-being, and is then accompanied by a new temperature wave. More often the tumor of glands disappears, but sometimes glands are inflated, opened or there is a heavy necrotic lesion of glands and surrounding cellulose;then it can go to sepsis.

    Other complications of scarlet fever should be noted serous synovitis( inflammation of the inner shell of the joint bag), manifested by increased temperature, pain and swelling of the joints. This complication occurs at the 1-2 nd week of the disease and does not pose a particular danger. Purulent arthritis appears in severe cases of sepsis and serves as a poor prognostic sign. The defeat of the respiratory tract is not characteristic of scarlet fever. However, in the form of severe complications, especially in young children, pneumonia and empyema( purulent pleurisy) are observed.

    The outcome in sepsis often ends with severe forms of septic and toxic-septic scarlet fever and, more rarely, suppurative complications with other forms of scarlet fever. When sepsis the child grows thin, badly eats, there are diarrheas, feverish condition, purulent complications( necrotic angina, purulent lymphadenitis, otitis, mastoiditis, etmoiditis, frontalitis, arthritis).The outcome of sepsis is more often lethal, especially in young children, but sometimes after a long, septic process for many weeks, recovery occurs.

    Criteria for severity in scarlet fever are:

    1. General symptoms of intoxication - state of consciousness, temperature reaction, multiple vomiting, other cerebral symptoms( convulsions), cardiovascular disorders.

    2. Local manifestations - the severity and nature of angina, rash.

    Outcomes of scarlet fever. Currently, light and medium-sized forms of scarlet fever predominate with a favorable outcome. Of the complications, the most frequent damage to the kidneys and myocardium, which requires mandatory monitoring( urine and ECG analysis) before discharge.

    Diagnostics. Diagnosis of scarlet fever in the acute period is based on typical clinical symptoms;presence of intoxication, sore throat, small-point rash with typical localization, white dermographism, "crimson tongue".In a later period, the diagnosis of scarlet fever can be made on the basis of detection of lamellar skin peeling, characteristic complications and data of epidemics.

    In scarlet fever, a small-point rash is the leading clinical symptom, so scarlet fever should be differentiated from infectious diseases occurring with exanthems( pseudotuberculosis, staphylococcal infection with scarlet fever, measles, rubella, infectious mononucleosis, enterovirus infection, chicken pox in the prodrome period), andnon-infectious, diseases: sweating, allergic dermatitis, insect bites).

    In pseudotuberculosis, unlike scarlet fever, there is a polymorphic character of the rash( small-spotted and spotty-papular, sometimes hemorrhagic).Localization of the rash around the joints creates a continuous erythematous background( a symptom of "gloves" and "socks").In pseudotuberculosis, diarrhea, abdominal pain, hepatosplenomegaly, which are not found in scarlet fever, are often noted.

    With staphylococcal infection with scarlet fever-like syndrome, one of the main clinical differences from scarlet fever is the presence of purulent foci of inflammation, except for sore throat( abscess, phlegmon, osteomyelitis, etc.), as well as the release of staphylococcus from the blood and other foci of infection.

    In measles, unlike scarlet fever, the rash is spotty-papular in character, appears on the 4th-5th day of the disease, in stages( face, trunk, lower limbs) followed by pigmentation. The appearance of the rash precedes catarrhal syndrome in the form of coughs, runny nose, conjunctivitis with photophobia and blepharospasm, the presence of spots of Velsky-Filatova-Koplik.

    When rubella rash patchy-papular, evenly distributed throughout the body, appears simultaneously with catarrhal symptoms, characterized by an increase in the posteroderma and occipital lymph nodes.

    Enterovirus infection, in contrast to scarlet fever, is often accompanied by multiple organ dysfunction( meningoencephalitic syndrome, myocarditis, myalgia, diarrhea, etc.).The exantheme is polymorphic, without a favorite localization and is short-lived. There is no purulent tonsillitis.

    In infectious mononucleosis, the leading syndromes are systemic enlargement of lymph nodes( polyadenopathy) and hepatoslenomegaly, against which a polymorphous rash, often triggered by the administration of penicillin drugs, may appear.

    With chicken pox in the prodromal period, before the occurrence of characteristic rash pox, a small-spot or spot-papular rash( syra) can be observed. However, it is short-lived and disappears without a trace within a few hours.

    For non-infectious exanthemes( allergic dermatitis, sweating, insect bites), there are no symptoms of intoxication and typical of scarlet fever( sore throat, localization of rash, white dermographism, "raspberry tongue").In addition, with allergic dermatitis, the rash is polymorphic and often accompanied by itching, as well as with insect bites.

    When rash, the localization of the rash resembles scarlet fever, but the absence of symptoms of intoxication, sore throats, as well as the moisture of the skin and signs of poor hygienic care make it possible to exclude scarlet fever.

    If there are fluctuations in the diagnosis between measles and scarlet fever, it is useful to recall Filatov's advice: "It's great that no one takes measles for scarlet fever, but always the other way around. .. The beginning doctor will be much less likely to make mistakes if he considers all dubious cases for scarlet fever".

    When diagnosed, the following typical signs of scarlet fever should be considered:

    1) the nature of the sore throat is a bright red color of the pharynx, passing to the soft palate to the solid boundary;

    2) pronounced lesion( swelling and tenderness when feeling) of the lymphatic submandibular glands, "crimson" tongue from the 4th-5th day of the disease;

    3) rash - rapid appearance and spread, small-scale character, free from the rash triangle on the face;if the rash is not enough, you can call it in the following way: a rubber band is placed on the middle of the shoulder and, 15 minutes later, a hemorrhagic effusion appears on the elbow bend( symptom Rumpel-Leede);

    4) the general course of the disease - acute onset, high fever, vomiting, sore throat;in the period of convalescence - the scaling and nature of complications;

    5) scarlet fever without rash( cases of angina in the scarlet fever) can usually be diagnosed only at the end of the 3rd week of the disease, with the appearance of ecdysis and typical complications.

    Laboratory diagnostics .Bacteriological - the main method of laboratory diagnosis, is aimed at isolating the pathogen from the mucous membrane of the oropharynx.

    Immunological methods( skin allergic test and serological tests) are aimed at establishing the immune response of the organism to the pathogen and its toxic products.

    Skin allergic test - Dick test - test for the presence of antibodies against erythrogenic toxin S. pyogenes in the body. For a positive reaction take the appearance at the site of administration of a toxin of an inflammatory infiltrate with a diameter of 10 mm or more. A positive test indicates a person's susceptibility to scarlet fever, a negative test for the presence of immunity. It is rarely used.

    Serological methods are aimed at the detection of erythrogenic toxin in RTGA, RC-agglutination, ELISA, PCR and antibodies to it by RIGA, ELISA, and RGA.

    Detection of IgM antibodies indicates a current acute infection, and the detection of IgG class is a chronic infection or a period of convalescence. Detection of IgM in combination with IgG indicates a persistent persistence. Tests aimed at determining the antibacterial immune response are only ancillary methods and have not been widely used in practice.

    Treatment of scarlet fever. The main principles of treating scarlet fever are:

    • diet therapy( mechanically sparing, dairy-vegetable);

    • bed rest in acute period( 5-7 days);

    • detoxification according to conventional regimens( OP and parenteral);

    • antibiotic therapy( macrolides, penicillins and other broad-spectrum antibiotics).

    Local treatment: irrigation or rinsing of the oropharynx( solutions of furacilin, Lugol, rotokana, imudon, yoks, hexoral, stopangin, tartum verde, etc.);

    • anti-inflammatory and immunotropic( immunon, lysobact);

    • desensitizing agents( dimedrol, suprastin, tavegil, zirtek, claritin, etc.);

    • symptomatic agents( antipyretic, etc.);

    • physiotherapy( quartz, UHF).

    It is necessary to note the mandatory and early administration of antibiotics, which is the prevention of complications. The course of antibacterial treatment is 5-7 days, and the route of administration( inside or parenteral) depends on the severity of the flow of scarlet fever.

    Hygienic content, suitable, full-fledged nutrition and careful observation of the patient are of tremendous importance for the course of the scarlet fever process. The chamber should be warm( 19-20 °), but it should be more often ventilated. Clean skin should be maintained in baths after 3 days, and during peeling - every other day. With severe damage to the cardiovascular system, the baths are replaced with wraps or wipes. Zev should be rinsed;To small children it is sprinkled several times a day with 3% solution of boric acid or 0.85% solution of sodium chloride. Lips, tongue and nasal mucosa prevent drying and cracks by lubricating with vegetable oil. With mucopurulent discharge from the nose, 2-3 drops of a 2% protargol solution are instilled in the nose.

    Diet in the early days of the disease should be semi-liquid: milk, kefir, curdled milk, porridge, jelly. With the end of acute events and the drop in temperature, therefore, from the 5th-10th day, it is possible to transfer the patient to a common table."Gentle" kidney milk or other inferior food does not protect against nephritis, but only depletes the patient. It is obligatory to give fruit and berry juices( vitamins).From the 10th day of the disease, it is necessary to examine the urine every other day( at least for protein) in order not to miss complications from the kidneys.

    A careful daily examination of the patient( ears, glands, joints) and thermometry is best used to identify complications. When jade appears, you need a strict bed rest and a strict diet. On the first day of jade detection a hunger diet is prescribed. The child is prescribed a sugar diet for 1-2 days: a solution of 100-200 g of sugar in 300-500 cm3 of water or tea or coffee-substitute with milk and sugar. To this can add 100 grams of white bread without salt. From the 4th day, if the swelling subsides and the amount of urine increases( to measure daily urine and the amount of liquid drunk per day), the drink is not restricted and gives yogurt, cottage cheese, butter, vegetable purees, bread without salt or with salt restriction to a minimum. When nausea, vomiting, headache and danger of uremia appear, they again limit the liquid( sugar or hungry day), completely eliminate salt and make a hot bath or wrap. With the onset of uremia, chloral hydrate is prescribed in the enema. Good bloodletting( 100 cm3) or release of 20-30 cm3 of cerebrospinal fluid. Descend from bed with nephritis can only after full recovery and the disappearance of urine protein, cylinders and blood.

    Lymphadenitis is best absorbed when applying heat( blue light, poultices, warming compress).With suppuration, a cut is made.

    With purulent otitis, paracentesis is performed, with mastoiditis, surgical intervention is necessary: ​​After the operation, the temperature drops after 1-2 days, the general condition improves considerably. Nephrite, flowing with mastoiditis, does not serve as a contraindication to surgery. Without surgery, mastoiditis leads to severe, often fatal complications: sinus thrombosis, meningitis, sepsis.

    With cardiovascular weakness, Sol is prescribed. Goffeini natrio-benzoici 2% for 1 teaspoonful( dessert) spoon 3-5 times a day( according to age), injections of camphor. Antipyretics should not be prescribed. At very high temperatures, it is best to use lukewarm baths, replaced with a bad pulse with cool wraps. On the head put a bubble with ice.

    With septic form and septic complications, penicillin should be prescribed for 25 000-50 000 units intramuscularly at 3 hours for several days in a row, depending on the severity of the course, age and therapeutic effect. Penicillin therapy significantly reduced mortality in septic forms of scarlet fever. Streptocide should be prescribed in the acute period of scarlet fever in a dose of 0.05-0.1 per kg of body weight before the disappearance of angina and reiterate the appointment for purulent complications. In severe septic cases it is necessary to combine penicillin and streptocide, while simultaneously resorting to stimulating therapy - blood transfusion or plasma transfusion of 100 cm3 2-3 times in 4-5 days.

    In toxic and toxic-septic forms, in all cases where there are intoxication phenomena( high temperature, frequent vomiting, poor pulse), it is necessary to immediately enter intramuscularly at Besedke antitoxic serum from 10 000 to 25 000 AE.If after 12 hours there is no drop in temperature, the general condition and pulse do not improve and the rash does not turn pale, then the same dose of serum is reintroduced, but immediately. After the 5th day of the disease, the serum is used less often, since by this time the initial severe toxic phenomena disappear, to which it has an effect.

    In toxic-septic forms, combined treatment with serum and penicillin or serum and streptocid is used.

    At the slightest suspicion of the presence of scarlet fever and diphtheria at the same time, or if a scarlet fever patient is infected with diphtheria, antidiphtheria serum in the amount of 5,000-10,000 AE is administered. Both serums can be administered simultaneously, which is absolutely necessary if the patient, in addition to severe intoxication, has necrosis in the throat. In rare cases, the result of the introduction of serum can be anaphylactic shock and often( 30-50%) serum sickness.

    The patient needs to be given a sufficient amount of fruit and berry juices( vitamins), which, apparently, weakens the manifestation of serum sickness.

    Before discharge from a scarlet fever patient necessarily examine the pharynx, nasopharynx, ears and produce a urine test. In the absence of complications and fever, it can be prescribed not earlier than 40 days from the onset of the disease.

    The prognosis for scarlet fever is determined primarily by the form of the disease. Mortality in severe septic and toxic-septic cases reaches 50% and higher, but it sharply decreases with specific therapy. A slightly better prognosis is in pure toxic cases due to the use of serum. With a moderate form of scarlet fever, mortality is 5-7%, and in light scarlet fever it is less than 1%.The prognosis is more serious in children under 3 years old. The additional infection associated with scarlet fever, such as influenza, diphtheria and especially measles, is extremely worsening the prognosis. A combination of scarlet fever and diphtheria is often observed. Any case of scarlet fever can be considered safely terminated only after full recovery.

    The dispensary observation is carried out by the local pediatrician within 1 month after the mild and moderate and within three months after the severe form of scarlet fever. During this period, the control of the general analysis of blood and urine is shown, according to ECG and ultrasound of the heart and kidney, in terms of treatment - vitamin therapy and restorative means. If necessary, an immunogram with subsequent correction.

    Anti-epidemic measures. Hospitalization of patients according to clinical and epidemiological indications. If you leave the patient at home, isolation stops after a full clinical recovery, but not earlier than the 10th day after the onset of the disease.

    Convalescents from among those attending pre-school institutions and the first two classes of the school after a clinical recovery undergo additional 12-day isolation. Patients with quinsy in the outbreak are infected with similar activities.

    Children under 10 years of age who have been in contact with a patient who have not previously had scarlet fever are suspended from visiting a children's institution for 7 days.

    Persons who have been in contact with a patient are observed for 7 days. Daily thermometry, examination of the oropharynx and skin are carried out.

    Specific prophylaxis is not developed.

    Anti-epidemic measures in the family-housing center are as follows:

    1. Isolation. Place the patient in an infectious hospital. With the early isolation of a scarlet fever patient, the risk of dispersal of infection among others is significantly reduced. In rare cases, mainly in relation to small children under 2 years old( the danger of hospital infection of measles, diphtheria and influenza), you can leave the patient at home, but under the following conditions: if you can allocate a separate, isolated room to the patient, and provide for carebehind him is one person who is subject to quarantine for the entire duration of the child's illness;if current and final disinfection is carried out, if there are no sick children and children attending schools and children's institutions in this apartment or room, or adults serving these institutions( teachers, educators, technical personnel, etc.);Sanitary supervision should supervise the hearth.

    2. Determination of the source of infection. Most often, this source of infection is in the immediate environment of the patient in the form of scarlet fever( angina in parents, carers and older children), scarlet fever in the infectious stage, or the patient with an obvious form of scarlet fever, who was in some way in contact withsurrounding children for several days of illness. Patients who are suspicious of scarlet fever( with sore throats, which cause suspicion that it is scarlet fever) should be sent to detention centers for 3 weeks after the onset of the disease. If these patients have to be left at home, then it is necessary to limit the possibility of a drop infection and contact them with others by taking personal prevention measures. During this period, it is possible to establish on the basis of a number of symptoms( ecdysis, typical complications for scarlet fever) the presence or absence of scarlet fever in these individuals. In convalescents suspected of spreading infection, it is important to establish the presence of complications from the throat, nasopharynx and ear or suppuration of the lymph glands. If possible, a mucus from the throat or nasopharynx should be examined for the carriage of hemolytic streptococcus. The return of a child who has transferred scarlet fever to a children's institution can be allowed only 12 days after discharge from the hospital, ie, not earlier than the 52nd day after the disease.

    3. Healthy children who have been in close contact with patients( children from the same family and apartments) are not admitted to schools and children's institutions for 12 days from the date of separation from the patient. In order to sanitize the pharynx, the pharynx and nasopharynx are irrigation 2-3 times a day with a solution of penicillin( 2,000 IU per cm3).Adults are subject to quarantine prior to sanitary treatment and final disinfection. To the school or children's institution that visited the patient, send a notification of the disease

    4. Wet disinfection of the things and premises of the patient, as well as public places( corridor, kitchen, restroom, etc.).The linen of the patient is soaked in disinfectant solutions or boiled. Bedding is better to be subjected to chamber disinfection. Less frequent gas disinfection with formalin.

    5. Children aged 1 to 9 years who have not had scarlet fever, can be actively vaccinated as prescribed by the doctor.

    When scarlet fever occurs in a children's institution, it is necessary to isolate from healthy children not only the sick, but also children and adults suspicious of scarlet fever( sore throats, jade after a sore throat, suspicious peeling, etc.).

    A thorough medical history and examination of all children and staff is mandatory. The nature of the disinfection( the measures are set in place during the epidemiological survey, in most cases, there is also a wet disinfection here.) The size of the quarantine is individualized depending on the type of institution. Naturally, the danger of a scarlet fever in the kindergarten or in the older groups of nurseries,, are particularly susceptible, more than in schools.

    Usually, with timely isolation of the patient and carrying out all of these activities, there are no recurrent diseases.

    Although scarlet fever can spread easily in a child's institution, it is not very contagious in ordinary day schools. If you received a message from the school that your child was in contact with a sick scarlet fever, do not go to sleepIn a panic, the chances of getting sick are small. The disease usually occurs one week after the infection. The quarantine rates vary widely in different districts.