Acute cholecystitis in a child with scarlet fever: a rare association.
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Group A streptococci are extracellular, Gram-positive pathogens responsible for pharyngitis, impetigo, scarlet fever, rheumatic fever and acute glomerulonephritis. Scarlet fever, which is rare nowadays owing to frequent antibiotic prescriptions in children, is caused by a toxin-producing Group A [beta]-haemolytic streptococcus found in secretions from the nose, throat, ears and skin.  The characteristic clinical features are exudative pharyngitis, fever and bright red exanthema. Otitis media, pneumonia, septicaemia, osteomyelitis, rheumatic fever and acute glomerulonephritis are the common complications associated with scarlet fever. However, hepatitis and vasculitis are other rare complications described in the literature. [2-4] Acute cholecystitis as a complication of typhoid and various viral infections such as Epstein-Barr virus, CMV and hepatitis A and B has been well described in the existing literature; however, the association of scarlet fever with acute cholecystitis has rarely been reported and its pathogenesis is not clear. [5-7] It has been postulated that the streptococcus enters the gall bladder through the mucous membrane of the stomach by way of lymphatic channel producing toxin and lymphocytic infiltration responsible for the lesion in the gallbladder as well in the liver.  Patients with acute cholecystitis due to scarlet fever usually present with fever, right upper abdominal pain, vomiting and jaundice. The diagnosis is based on clinical manifestation, laboratory investigations (leukocytosis, abnormal liver function tests) and ultrasonographic findings (gallbladder distension, gall bladder wall thickness (>3.5 mm), non-shadowing echogenic materials or sludge, and pericholecystic fluid collections); however, these may sometimes be ambiguous and confusing in children.  The management is usually non-operative although cholecystectomy may be required. [7,8]
Scarlet fever is usually a benign disease, but may develop serious complications. Acute cholecystitis should be suspected in a child presenting with an acute abdomen associated with scarlet fever. Urgent ultrasound of the abdomen, along with laboratory investigations, is warranted to diagnose acute cholecystitis.
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[5.] Gora-Gebka M, Liberek A, Bako W, et al. Acute acalculous cholecystitis of viral etiology-a rare condition in children? J Pediatr Surg 2008;43(1):e25-27. DOI:10.1016/j.jpedsurg.2007.10.073
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[7.] Yasuda H, Takada T, Kawarada Y, et al. Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14(1):98113. DOI:10.1007/s00534-006-1162-9
[8.] Imamoglu M, Sarihan H, Sari A, Ahmetoglu A. Acute acalculous cholecystitis in children: Diagnosis and treatment. J Pediatr Surg 2002;37(1):36. D0I:10.1053/jpsu.2002.29423
Y Parvez, MBBS, MD, MRCPCH, MRCPS, DCH (UK); S Thomas, MBBS, MD Department of Pediatrics, Dubai Hospital, United Arab Emirates
Corresponding author: Y Parvez (firstname.lastname@example.org)
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|Title Annotation:||CASE REPORT|
|Author:||Parvez, Y.; Thomas, S.|
|Publication:||South African Journal of Child Health|
|Date:||Sep 1, 2016|
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