PBL 1: SWALLOWING HURTS

SUMMARY
10 year old boy with sore throat and fever for the last 3 days.
He was also complaining of pain on swallowing with loss of appetite, headache,
nausea and one episode of vomiting.
LGs
Gram-positive cocci:
Staphylococcus aureus is a gram-positive, catalase-positive, coagulase-positive
cocci in clusters. S. aureus can cause inflammatory diseases, including skin
infections, pneumonia, endocarditis, septic arthritis, osteomyelitis, and
abscesses. S. aureus can also cause toxic shock syndrome (TSST-1), scalded skin
syndrome (exfoliative toxin, and food poisoning (enterotoxin).
Staphylococcus epidermidis is a gram-positive, catalase-positive, coagulase-
negative cocci in clusters and is novobiocin sensitive. S. epidermidis commonly
infects prosthetic devices and IV catheters producing biofilms. Staphylococcus
saprophyticus is novobiocin resistant and is a normal flora of the genital tract
and perineum. S. saprophyticus accounts for the second most common cause
of uncomplicated urinary tract infection (UTI).
Streptococcus pneumoniae is a gram-positive, encapsulated, lancet-shaped
diplococci, most commonly causing otitis media, pneumonia, sinusitis, and
meningitis. Streptococcus viridans consist of Strep. mutans and Strep
mitis found in the normal flora of the oropharynx commonly cause dental
carries and subacute bacterial endocarditis (Strep. sanguinis).
Streptococcus pyogenes is a gram-positive group A cocci that can cause
pyogenic infections (pharyngitis, cellulitis, impetigo, erysipelas), toxigenic
infections (scarlet fever, necrotizing fasciitis), and immunologic infections
(glomerulonephritis and rheumatic fever). ASO titer detects S.
pyogenes infections.
Streptococcus agalactiae is a gram-positive group B cocci that colonize the
vagina and is found mainly in babies. Pregnant women need screening for
Group-B Strep (GBS) at 35 to 37 weeks of gestation.
Enterococci is a gram-positive group D cocci found mainly in the colonic flora
and can cause biliary tract infections and UTIs. Vancomycin-
resistant enterococci (VRE) are an important cause of nosocomial infections.
 Prevention and infection control in term of patient safety for the Gram
positive cocci infection.
Standard precautions
Measures Field of systematic application of the measures

Hand hygiene Hand disinfection:

– After contact with blood, body fluids, secretions,

excretions, contaminated items

– Immediately before gloving and after glove removal

– Between any contacts with any patients

Hand washing:

– For macroscopically dirty hands before and/after any care

Gloves For anticipated contact:

– With blood, body fluids, secretions, excretions,

Measures Field of systematic application of the measures

contaminated items

– With mucous membranes, and/or nonintact skin

Importantly:

– Hands have to be systematically disinfected after glove

removal

Mask, eye To protect mucous membranes of the eyes, nose and

protection, and mouth during procedures and patient-care activities likely
face shield to generate splashes or spray of blood, body fluids,
secretions and excretions

Gowns To protect skin and prevent soiling of clothing during

procedures and patient-care activities likely to generate
splashes or spray of blood, body fluids, secretions and
excretions

Impermeable gown should be used when appropriate

Rheumatic fever may develop after strep throat or scarlet fever infections that
are not treated properly. Bacteria called group A Streptococcus or group A
strep cause strep throat and scarlet fever. It usually takes about 1 to 5 weeks
after strep throat or scarlet fever for rheumatic fever to develop. Rheumatic
fever is thought to be caused by a response of the body’s defense system —
the immune system. The immune system responds to the earlier strep throat
or scarlet fever infection and causes a generalized inflammatory response.
Children Most Often Affected
Although anyone can get rheumatic fever, it is more common in school-age
children (5 through 15 years old). Rheumatic fever is very rare in children
younger than three years old and adults.

Infectious illnesses, including group A strep, tend to spread wherever large

groups of people gather together. Crowded conditions can increase the risk of
getting strep throat or scarlet fever, and thus rheumatic fever. These settings
include:

 Schools
 Daycare centers
 Military training facilities
Someone who had rheumatic fever in the past is more likely to get rheumatic
fever again if they get strep throat or scarlet fever again.

Symptoms of rheumatic fever can include:

 Fever
 Painful, tender joints (arthritis), most commonly in the knees, ankles,
elbows, and wrists
 Symptoms of congestive heart failure, including chest pain, shortness of
breath, fast heartbeat
 Fatigue
 Jerky, uncontrollable body movements (called “chorea”)
 Painless lumps (nodules) under the skin near joints (this is a rare
symptom)
 Rash that appears as pink rings with a clear center (this is a rare
symptom)
In addition, someone with rheumatic fever can have:

 A new heart murmur

 An enlarged heart
 Fluid around the heart

What is tonsillar exudate?

Tonsillar exudate refers to a fluid that is secreted by the tonsils in response

to tonsillitis, also known as inflammation of the tonsils. The exudate fluid is
usually made up of cells and proteins, as well as leukocytes
and neutrophils (infection-fighting white blood cells), involved in eradicating
the infectious virus or bacteria causing the tonsillitis.
Acute rheumatic fever is a multiorgan inflammatory disorder affecting the
heart, joints, brain, and skin. The pathogenic mechanism of molecular mimicry
involves autoantibodies and T cells directed against group A streptococcal cell
wall components and heart or brain antigens that have been extensively
investigated. Autoantibodies and T-cell responses in rheumatic heart disease
and Sydenham chorea induce valve disease with heart murmurs and
movement and behavioral disturbances, respectively. In carditis,
autoantibodies and T cells target valve proteins while in Sydenham chorea the
autoantibodies deposit in the brain and target the basal ganglia and
dopaminergic neurons.
Serious Complications Include Long-term Heart Damage
If a streptococcal infection is not treated promptly, several complications may
develop. In some cases, rheumatic fever (a disease affecting the heart, joints,
brain, and skin) can develop. In other cases, a peritonsillar abscess—which is
an infected pocket of pus near one of the tonsils—can form. A peritonsillar
abscess can lead to the spread of infection throughout the body;
Serious Complications Include Long-term Heart Damage
If rheumatic fever is not treated promptly, long-term heart damage (called
rheumatic heart disease) may occur. Rheumatic heart disease sweakens the
valves between the chambers of the heart. Severe rheumatic heart disease can
require heart surgery and result in death.

In many cases of patients who had rheumatic fever--at times undiagnosed--

there is a chronic involvement of the brain as a result of disseminated
recurrent obliterating arteritis or emboli in the small blood vessels, especially
in the brain membranes or the cortex.

Good Hygiene Helps Prevent Group A Strep Infections

The best way to keep from getting or spreading group A strep infections such
as strep throat or scarlet fever is to wash your hands often, especially
after coughing or sneezing and before preparing foods or eating.

Treatment often include:

 Antibiotics, such as penicillin, to eliminate any remaining strep bacteria.

 Long-term antibiotic treatment to prevent recurrence.
 Nonsteroidal anti-inflammatory drugs (NSAIDs), such
as naproxen or ibuprofen, to reduce inflammation and pain
 Corticosteroids, such as prednisone, may be used if inflammation is
severe
 Other medications may be given to reduce severe involuntary
movements
Aspirin is no longer recommended for the symptomatic management of joint
pain in rheumatic fever. Paracetamol, naproxen or ibuprofen can be used for
the symptomatic management of joint pain in rheumatic fever
Ibuprofen reduces pain, fever, swelling, and inflammation by blocking the
production of cyclooxygenase (COX)-1 and COX-2. The body releases these
substances in response to illness and injury. If a person takes ibuprofen by
mouth, they should notice the effects after 20–30 minutes
Ibuprofen is well tolerated and readily available but data and experience
with its use is less in ARF than naproxen. The dose of NSAIDS needed for ARF
is generally higher than the dose recommended for other conditions, therefore
it may be appropriate to commence at the higher dose range.
The main mechanism of action of ibuprofen is the non-selective, reversible
inhibition of the cyclooxygenase enzymes COX-1 and COX-2 (coded for by
PTGS1 and PTGS2, respectively

Side effects of ibuprofen

 Headaches. Make sure you rest and drink plenty of fluids. ...
 Feeling dizzy. If ibuprofen makes you feel dizzy, stop what you're doing
and sit or lie down until you feel better. ...
 Feeling sick (nausea) Stick to simple meals. ...
 Being sick (vomiting) ...
 Wind. ...
 Indigestion
Who may not be able to take ibuprofen. Do not take ibuprofen by mouth or
apply it to your skin if you: have ever had an allergic reaction or symptoms like
wheezing, runny nose or skin reactions after taking aspirin, ibuprofen or other
non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen. are
pregnant.

PENICILLIN
People with a history of rheumatic fever are at high risk of recurrent attacks of
rheumatic fever and developing rheumatic heart disease following a
streptococcal throat infection. Giving penicillin to these people can prevent
recurrent attacks of rheumatic fever and subsequent rheumatic heart
disease.
Penicillin kills bacteria through binding of the beta-lactam ring to DD-
transpeptidase, inhibiting its cross-linking activity and preventing new cell
wall formation. Without a cell wall, a bacterial cell is vulnerable to outside
water and molecular pressures, which causes the cell to quickly die.
Common signs and symptoms of penicillin allergy include hives, rash and
itching. Severe reactions include anaphylaxis, a life-threatening condition that
affects multiple body systems.
Cephradine is in a group of drugs called cephalosporin (SEF a low spor in)
antibiotics. Cephradine fights bacteria in the body.
Cephradine is used to treat infections caused by bacteria, including upper
respiratory infections, ear infections, skin infections, and urinary tract
infections.
Cefradine, like the penicillins, is a beta-lactam antibiotic. By binding to specific
penicillin-binding proteins (PBPs) located inside the bacterial cell wall, it
inhibits the third and last stage of bacterial cell wall synthesis.
Cephradine side effects
 diarrhea that is watery or bloody;
 fever, chills, body aches, flu symptoms;
 tightness in your chest;
 unusual bleeding;
 seizure (convulsions);
 pale or yellowed skin, dark colored urine, fever, confusion or weakness;
 jaundice (yellowing of the skin or eyes);
REFEERENCES
levinson microbiology and immunology
https://www.cdc.gov/groupastrep/diseases-public/rheumatic-fever.html
https://www.nhs.uk/medicines/ibuprofen-for-adults/side-effects-of-
ibuprofen/
https://www.researchgate.net/figure/1-Classification-of-
Antibiotics_tbl1_330533072
https://www.ncbi.nlm.nih.gov/books/NBK470553/
https://www.sciencedirect.com/science/article/pii/
S1198743X15301208#:~:text=Patients%20with%20suspected%20or
%20confirmed,followed%20by%20systematic%20hand%20disinfection.