A 4-year-old boy is brought to the office due to skin lesions on his chin for the past 2 days. Temperature is 36.1 C (97 F). The patient is well-appearing. There are mildly tender perioral papules and pustules, some of which appear to have broken down and are covered with amber-colored crusting. A wound culture is taken, and Gram stain shows gram-positive cocci in chains. Which of the following symptoms would be most likely to develop as a potential complication of this patient's infection?

Question

A 4-year-old boy is brought to the office due to skin lesions on his chin for the past 2 days.  Temperature is 36.1 C (97 F).  The patient is well-appearing.  There are mildly tender perioral papules and pustules, some of which appear to have broken down and are covered with amber-colored crusting.  A wound culture is taken, and Gram stain shows gram-positive cocci in chains.  Which of the following symptoms would be most likely to develop as a potential complication of this patient's infection?

Quizplus · Accepted Answer

11ec160b_3859_4b28_9249_cbcb82da9e09_MD0001_00 This child has impetigo, a superficial bacterial infection that most commonly develops on the face or extremities in children. Patients usually develop mildly itchy or painful erythematous papules and pustules that later erupt, forming a honey-colored crusting. The most common pathogen is Staphylococcus aureus followed by group A Streptococcus (GAS, S pyogenes). Treatment of localized impetigo is with topical antibiotics (eg, mupirocin), and most patients have no long-term sequelae. However, a minority of patients may develop poststreptococcal glomerulonephritis (PSGN) several weeks after impetigo caused by GAS (as indicated by this patient's Gram stain showing gram-positive cocci in chains). Renal damage is caused by immune complex deposition as well as complement activation, leading to a massive inflammatory response that damages the glomerular basement membrane. Symptoms of PSGN range from asymptomatic, microscopic hematuria to gross hematuria and nephrotic-range proteinuria. In addition to tea- or cola-colored urine, patients may develop periorbital/facial swelling, generalized edema, and hypertension. Laboratory evaluation typically reveals elevated creatinine and decreased complement C3 level. (Choice A) Ascending weakness is a classic feature of Guillain-Barre syndrome, which may be preceded by an upper respiratory or gastrointestinal (eg, Campylobacter jejuni) infection. GAS disease is not associated with this condition. (Choice C) Fatigue and a new heart murmur due to carditis can be manifestations of acute rheumatic fever, a potential poststreptococcal sequelae associated with GAS pharyngitis. This disease is not associated with impetigo in developed regions, although this relationship is less clear in some parts of the developing world. (Choice D) Eye redness (due to conjunctivitis or anterior uveitis) and joint pain may be seen in reactive arthritis, which typically occurs following a diarrheal (eg, Salmonella) or genitourinary (eg, chlamydial) infection, not impetigo. (Choice E) Unilateral facial drooping due to a facial nerve palsy (ie, Bell palsy) is often associated with herpes simplex virus infection, not impetigo. Educational objective: Poststreptococcal glomerulonephritis is a potential complication of group A streptococcal infection (eg, impetigo, pharyngitis). Symptoms include proteinuria (often associated with periorbital or generalized edema) and hematuria. Acute rheumatic fever is a postinfectious sequelae of streptococcal pharyngitis only, not impetigo. __________ References: Impetigo: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25250996) Poststreptococcal glomerulonephritis. (http://www.ncbi.nlm.nih.gov/pubmed/30855843)

A 4-Year-Old Boy Is Brought to the Office Due to Skin