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        -----Original Message-----
        From:   Eran Kozer [SMTP:[log in to unmask]]
 
        How would you treat a well appearing 3 years old child with
        Varicella who still has a fever (39 C) on the 4th day of his
        illness?
        The committee on infectious diseases in its statement on
        "Invasive Streptococcal infections" (Pediatrics January
        1998) states that in such a case the possibility of invasive
        Streptococcal infection should be considered. However the
        diagnosis of invasive Streptococcal infection is not an easy
        one . Cellulitis  and leukocytosis are not always present
        and these patients are seen by many Physicians before an
        accurate diagnosis is  made (Doctor A. et al. Pediatrics
        1995) .
        So, would you admit  such a child for perentral antibiotic
        treatment?
 
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I refer you to the following must read article that answers some of your
questions.
"Invasive GAS infections in Canada" NEJM August 1996 Vol 335(8).
 
        The invasive GAS infections present either as TSS or necrotizing
fascitis in the setting of varicella. Unless I suspect it clinically
based on some objective sign or symptom I don't necessarily admit them.
 
 
        S/S that would make me suspect TSS with varicella in your
patient would be: hypotension, wide pulse pressure, erythroderma,
syncope, vomiting, mucositis, diffuse myalgias, altered renal or liver
functions.
 
        S/S of early necrotizing fascitis would be pain out of
proportion to cutaneous varicella lesions or focal deep muscle
tenderness.
 
        I agree that cellulitis or leucocytosis is not necessary to
establish a diagnosis of invasive GAS. Also, I like to treat these
patients with cellulitis and varicella with Clindamycin (IV or PO) even
if they don't have evidence for invasive disease, because of the
potential serious nature of the problem. There is some evidence that the
latter halts toxin production by being bacteriostatic and inhibiting
cellular ribosomal protein synthesis.
 
        Hope that helps
 
        [Jay Pershad, M.D.]
 
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