Female patient, 6 years old, with a history of Down syndrome, hypothyroidism in treatment and congenital heart disease operated in her first year of life (atrioventricular canal and patent ductus arteriosus).
There were daily vaccines from the National Immunization Program (NIP) without extra-PNI vaccines.
She presented with fever and erythrodermia twice at the Pediatric Emergency Department (PED) four and five days after onset.
Erythema began in one side and then spread to the contralateral side.
On the second day, the patient presented fever up to 40°C, with increased erythema in descending progression, which compromised the neck, trunk and both upper extremities.
It was also accompanied by the appearance of three non-pruritic erythematous blisters in the preauricular and chin region that disappeared spontaneously during the course of the day.
It was evaluated with laboratory tests, highlighting a blood count with normal leukocyte count (10.470/mm3) with polymorphonuclear predominance (92.3%), without alteration of red series and C-reactive protein (CRP) of 6.5 mg/dl.
Allergic dermatitis was diagnosed and oral chlorhexidine and glucocorticoids were prescribed for three days.
Due to persistent symptoms, he consulted his treating pediatrician who referred him again to the ICU.
At that time, on her 8th day of evolution and 7th day of fever, she was in good general condition.
On physical examination, a "erythro-desquamative lesion on the face that respected the perioral area and an erythematous plaque on the upper extremities that respected the stumps, hands and foreheads were described.
It also affected the scalp, neck and upper half of the trunk, with well-defined borders, without palpable adenopathies.
He had a conjunctival injection without secretion and a baffled tongue.
The cardiac examination was normal and showed no periungual desquamation".
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Laboratory tests were requested, highlighting a blood count with leukopenia of 4.880/mm3, with polymorphonuclear predominance (90%), platelets 198.000/mm3, CRP of 20.2 mg/dl and anti-streptococcal antibodies (O59).
A pharyngeal culture and two peripheral blood cultures were also taken.
He was admitted to the Pediatrics Department on the 8th day of evolution, in good general conditions, with hemodynamic stability and without consciousness compromise.
The diagnosis of scarlatin was raised and antimicrobial treatment with oral amoxicillin was initiated.
In addition, the need to perform an echocardiogram to rule out Kaaki disease or infectious endocarditis was raised.
Tests were monitored 24 hours after admission.
The CRP was 23.9 mg/dl and the biochemical profile was normal.
Evaluated by infectology, it was decided to change antimicrobial treatment to sodium penicillin IV.
It was established from the beginning of antimicrobial treatment in good general conditions.
After 48 hours, two positive hemocultives for Streptococcus ß-hemolytic group G were informed, with in vitro susceptibility to penicillin, clindamycin, cloxacillin, er lexacillin.
The echocardiogram was normal and there was no detection of other secondary clinical foci.
Erythema multiforme, erythema multiforme
On the 5th day of antimicrobial treatment, it was reported that the species identified by the Vitek® method corresponded to Streptococcus dysgaia equisimilis.
The patient received 10 days of intravenous antimicrobial treatment plus four days of amoxicillin/clavulanic acid orally, completing 14 days of treatment in the outpatient phase.
The subsequent control showed a satisfactory evolution.
A basic study of immunodeficiency ruled out hypogammaglobulinemia, hypocomplementemia or leukopenia secondary to Down syndrome.
The strain was sent to the Molecular Biology Laboratory of the Catholic University for constipation.
The universal PCR technique confirmed Streptococcus equigasimi subespecielis, stg653.0 genotype.
