Complications of strep.
There are unfortunately a lot of potential complications
of partially treated or untreated strep throat infection.
We're gonna go through some
of these in greater detail.
The first is rheumatic fever.
This is a serious complication of strep throat.
It is that if the strep bacteria is not completely
eradicated, it can remain in the tonsils
and promote a persistent
immune response from the body.
This ongoing immune response to the strep
bacteria can trigger the immune system
to mistakenly attack the other organs in the body
including the patient's joints and heart valves.
Patients with rheumatic fever
will typically have a fever.
They will also have painful,
hot, swollen and tender joints.
They may have small, painless bumps beneath
their skin and these are called nodules.
The patient can develop a heart
murmur as the valves get damaged.
And they may have flat or slightly raised, painless rash
on their chest or abdomen called erythema marginatum.
The patient can also develop jerky,
uncontrollable body movements called chorea.
Treatment with the appropriate antibiotics even if started
several days after the resolution of the infection
can prevent acute rheumatic fever.
Fortunately, Scarlet fever or rheumatic fever is
now less common than in the pre-antibiotic era.
Another complication of strep throat
is called glomerulonephritis.
Similar to acute rheumatic fever,
an immune response in the kidneys
can result in kidney inflammation
called post strep glomerulonephritis.
Unlike rheumatic fever though,
there is no evidence that shows
that the treatment of the strep
throat will prevent this condition.
Therefore, a patient who has been perfectly treated for
their strep throat can still develop this complication.
This condition is more common than rheumatic fever
and it typically resolves after a few weeks
and it does not usually cause
permanent damage to the kidneys.
Remember, your kidneys are your filters.
They filter your total blood
volume about 60 times per day.
In glomerulonephritis, the glomeruli which
are these tiny filters, become inflammed.
The glomeruli are responsible for removing excess
fluid, electrolytes and wastes from the bloodstream
and they pass them into the urine
for removal from the body.
These are signs and symptoms of
post strep glomerulonephritis.
The patient can have a microscopic hematuria which means,
when you look at the urine in a cup, it's not visible.
Another potential sign of glomerulonephritis is called
gross hematuria and this is blood that you can see.
When you look in the urine cup, it can look like cola,
it's a dark brown hue and this is due to the blood.
The patient can also have a decreased
urine output and this is called oliguria.
This is defined as a urine output less than 1 ml/kg/hr
in infants, less than 0.5 ml/kg/hr in children
and less than about 30 ml/hr in adults,
although the criteria could vary.
Your patient with glomerulonephritis
may also have edema.
This may be mild,
moderate or severe.
And this can be found on the feet, so pedal edema
and periorbital, on the face around the eyes.
Patients with glomerulonephritis
may also present with hypertension
and this is because of the kidney's involvement
in controlling the blood pressure.
This may be mild,
moderate or severe.
Patients can also develop otitis
media, meningitis, pneumonia
and toxic shock syndrome as
complications of strep throat.
A more common complication is the formation of an
abscess in the peritonsillar or retropharyngeal space.
Here we see a healthy throat,
it's symmetric bilaterally.
If the strep throat infection can break out of the tonsillar
region and into the surrounding areas, an abscess can form
and this is an encapsulated pocket of pus.
The formation of an abscess behind the throat or in
the retropharyngeal space due to untreated strep
can lead to severe illness causing pain in the throat and
the neck, problem swallowing and respiratory compromise.
These abscesses are in the peritonsillar
or retropharyngeal space.
And how do we treat these?
Well, antibiotics can be used but really, truly,
definitive treatment involves an incision of the abscess.
This is done by lancing or cutting
the abscess to release the fluids.
The contents can also be aspirated with
a needle and typically this is done
by an ear, nose and throat specialist
or an emergency department provider
because the patient usually needs
pain control and rehydration.
Here we see an abscess.
This patient is gonna present with a classic
symptom of a unilateral sore throat.
So with typical viruses and typical strep
throat infection, the patient comes in
and they have an equal sore throat
on both sides, it is bilateral.
But when the patient presents and they say,
"My throat only hurts on the right."
or "My throat only hurts on the left,"
You need to have a high index of suspicion
for the patient having an abscess.
The patient may have dysphagia
which is difficulty swallowing
and this can make it difficult or impossible for them
to swallow food or fluids or even their own saliva.
The patient may be drooling
and have fever or chills.
Trismus may be present and this is
difficulty opening the mouth fully.
And this can be due to the pressure of the
abscess actually pushing on the muscles.
The patient may have swelling of the face
or neck and may have a muffled voice.
The clinician's going to feel for
lymphadenopathy as well and you wanna be sure
not to confuse the feeling of an abscess
with the feeling of an enlarged lymph node.
So what's a tonsillectomy?
A tonsillectomy is a surgical procedure in which both of the
palatine tonsils are fully removed from the back of the throat.
While the surgeon is there, they
may also remove the adenoids.
There are a few reasons why the
tonsils and adenoids may be removed.
The first is patients who get recurrent strep throat.
We know that strep throat can cause
problems with school and work
as the patient needs to stay out
of the community for 24 hours
and these patients are on constant antibiotic
therapy, so they might take their tonsils out.
Another would be recurrent tonsillitis
and patients with snoring or sleep apnea
may also have their tonsils removed.
So what are the nursing implications when you're
taking care of a patient who's had a tonsillectomy?
Well, you wanna monitor their vital signs closely.
These patients have had surgery in their throat
and they can have post op surgical complications
that may only be seen with
a change in vital signs.
You're gonna need to manage the patient's
pain and this is in the acute phase
and then in the post op a couple of days after.
You're gonna want to monitor bleeding and this
involves looking in the back of the throat
and actually observing for bleeding
in the posterior oropharynx.
Slowly as the patient's pain gets under control,
they're gonna be able to advance their diet
from a clear liquid diet, to soft
foods and on to a regular diet.