Minor Case Study: Pediatrics
Strep Induced Sepsis
Emily Brantley
Andrews University
Dietetic Intern
1
Introduction
MT is a 16 year old black male who is 170.18 centimeters tall and weighs 67 kilograms.
He was admitted to The Florida Hospital for Children with fever, sepsis and toxic shock related
to strep throat. I chose to conduct a case study on this patient because this is the first occasion
that I have ever personally witnessed sepsis beyond a textbook or educational setting. What
was especially appealing to me in this circumstance was the fact that such a severe condition
presented itself in a previously healthy adolescent. This case study began on February 4, 2014
and ended four visits later on February 7, 2014. The focus of this study is sepsis since it is the
first major health trauma MT has ever experienced.
Social History
MT lives at home with his mother, father, sister and grandparents. He is in the 10th
grade at Wekiva High School where he participates in basketball. Currently, he is covered by his
parents Aetna health insurance. MT and his immediate family is Baptist. During his stay, MT’s
immediate and extended family showed their support by being present daily during his
recovery process and hospitalization.
Normal Anatomy and Physiology of Applicable body functions
Strep throat is an infection that inhabits the throat and tonsils. It is caused by the
streptococcus bacteria. There are many different strains of streptococcus that are identified in
different groupings. Group A streptococcus is the strain that is most often associated with the
infection that causes strep throat because this particular streptococcal bacteria can live in a
person’s nose and throat. Group A strep infections can range from minor superficial skin
infections and strep throat to serious and life-threatening illnesses such as toxic shock
syndrome. These severe cases may occur when the bacteria get into parts of the body where
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bacteria usually are not found, such as the blood. The presence of bacteria in the bloodstream
is known as bacteremia. Bacteremia can spread infection to other organs and even cause
symptoms such as fever, rapid heart rate and low blood pressure that may lead to sepsis. 1&2
Sepsis has traditionally been defined as an uncontrolled inflammatory response to
infection or trauma. Today, it is understood that sepsis is a systemic inflammatory response and
immunosuppressive process that prevents a sufficient response to infection or to trauma. There
is hyper-metabolic catabolism of the metabolic stress response. In more straightforward terms,
sepsis is defined as a condition in which the body has a severe reaction to bacteria or other
germs. The unpredictability of this systemic response relates in part to the health status and
age of the patient.1&2
There are many physiologic and metabolic changes that arise from sepsis. These
changes are complex and they encompass most of the body’s metabolic pathways. The earliest
principal signs of sepsis include the following:
3

White blood cell count (>12,000 mm3)

Respirations (>20 breaths/minute)

Increased heart rate (>90 beats/minute)

Fever (>38 °C) or hypothermia (<36 °C).
Sepsis is associated with an increase in inflammatory proteins that decrease iron
reutilization, erythropoiesis, and hematological function. Fever and sepsis are common causes
of respiratory alkalosis. Sepsis can increase C-reactive protein, fibrinogen, complement
proteins, and other acute-phase proteins. Suggestive laboratory values can include elevated
serum lactate and serum glucose. Sepsis has been shown to create hyperglycemia, even in
patients with no previous history of diabetes mellitus. Additionally, creatinine excretion is
increased by sepsis.1&3
Past Medical History
MT’s hospital records indicate that he was a previously healthy teenager. There was no
record to indicate that MT had any significant past medical history. This episode of sepsis has
led to MT’s first serious hospital stay.
Present Medical Status and Treatment
Theoretical discussion of the disease
Sepsis is initiated by an originating source of infection and/or trauma. As previously
mentioned, sepsis is initially a serious inflammatory response. As sepsis progresses, a shift from
an inflammatory response to an anti-inflammatory response follows resulting in an inability to
support an immune response. This eventually leads to organ dysfunction and hypo-perfusion,
or decreased blood flow through an organ. In sepsis, there is an increased rate of
gluconeogenesis that results in significant catabolism, or breakdown of skeletal muscle mass.
These metabolic irregularities result in hyperglycemia and increased serum lactate.1
4
Even with tremendous advances in understanding the pathophysiology of sepsis, the
morbidity and mortality accredited to sepsis remains exceptionally high. “Increasing evidence
has linked the administration of maternal intra-partum antibiotics with the emergence of
resistant bacterial strains.”4 It is apparent that while a great deal is now understood about the
biological and molecular actions involved in sepsis, this understanding has yet to be translated
into innovative new strategies. Sepsis is now classified as one of the leading causes of death in
children with an estimated 4,400 deaths that occur annually in the United States alone.5 On the
other hand, there are more than 10 million cases of mild Group A Strep infections, such as skin
and throat infections, are diagnosed each year according to the National Institute of Allergy and
Infectious Diseases (NIAID).6
Specifically, pediatric sepsis accounts for an estimated annual health care cost of $2
billion in the United States.5 There are between 9,000 and 10,000 cases of more serious
streptococcal infections, including toxic shock syndrome and necrotizing fasciitis that occur
annually. People with immune systems weakened by diseases such as diabetes or cancer, are at
a greater risk for developing serious Group A Strep infections.6
Usual Treatment of the condition
Evidence-based medical treatment protocols have been established to address the
immediate management of sepsis. Primary treatment focuses on originally treating the source
of the infection. In a seminal study of over 1100 patients, the prearrangement of appropriate
anti-microbial coverage at least one day prior to identification of the organism was associated
with improved survival. 5
5
Supporting the patient with ventilation, antibiotics, and metabolic support is also
imperative. In the first hours following clinical presentation of sepsis, the goal is to maintain
oxygenation and ventilation and achieve normal balance. In the occurrence of metabolic
acidosis related to septic shock, the work of breathing accompanying the compensatory
respiratory alkalosis can be substantial. Metabolic acidosis along with fever can contribute to a
significant portion of oxygen consumption. Early intubation and positive pressure mechanical
ventilation is considered because myocardial dysfunction – which is often present in children
with sepsis – can be enhanced by the implementation of positive pressure ventilation. In
addition to oxygen, antibiotics and large amounts of fluids are given through a vein as
treatment. 1&5
Patient’s Symptoms upon Admission Leading to Present Diagnosis
According to MT’s mother, MT had symptoms of sore throat and fever for 24- 48 hours.
She took MT to urgent care where he was treated for strep with oral penicillin. Afterward, MT
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continued to do poorly with physical declination. His oral intake remained low and MT’s fevers
did not diminish.
MT was admitted through the Emergency department with a sore throat, fever,
headache, fatigue and poor oral intake. In the Emergency department, MT had a central line
placed because he was found to have severe metabolic acidosis with lactic acidosis and
hypotension. MT was diagnosed with septic shock and transferred to the Pediatric ICU for
further monitoring.
Laboratory Findings and Interpretation
The Laboratory findings for MT from February 4th – February 7th were as follows:
Lab
Normal Ranges
Sodium
Potassium
BUN
Creatinine
Blood
Glucose
Albumin
Temperature
135 to 145 milliequivalents per liter (mEq/L)
3.7 to 5.2 mEq/L
7 to 20 mg/dL
0.6 to 1.1 mg/dL for women
70 to 100 milligrams per deciliter (mg/dL)
Visit 1
2/4/14
136
3.9
26
1.28
148
3.5 to 5.4 grams per deciliter (g/dL)
96.8 to 98.6 degrees Fahrenheit (˚F)
1.8
101.9˚
Lab Values
Visit 2 Visit 3
2/5/14 2/6/14
134
140
3.9
3
23
17
1.27
0.95
116
130
Visit 4
2/7/14
139
3.1
18
0.81
148
1.5
100.9˚
2.6
99.9˚
2.0
99.8˚
7
Medications
Below is a table that explains the uses and purpose of MT’s medications along with their
food/drug interactions and side effects.
Drug Name
Uses
Rocephin
(Ceftriaxone)
Intravenous fluid in the
cephalosporin antibiotic class of
medications used to treat certain
infections caused by bacteria.
Clindamycin
Used to treat certain types of
bacterial infections, including
infections of the lungs, skin,
blood, and internal organs. It
works by slowing or stopping the
growth of bacteria. Clindamycin
is in the class of medications
called lincomycin antibiotics.
Used to treat ulcers, gastroesophageal reflux disease and
conditions where the stomach
produces too much acid.
Famotidine is in a class of
medications called H2 blockers
that works by decreasing the
amount of acid made in the
stomach.
Used to prevent blood clots from
forming in certain medical
conditions or certain medical
procedures that increase the
chance that clots will form; used
to stop the growth of clots that
have already formed in the blood
vessels, but it cannot be used to
decrease the size of clots that
have already formed; used in
small amounts to prevent blood
clots from forming in catheters
that are left in veins over a
period of time. Heparin is in a
Pepcid
(Famotidine)
Heparin Flush
Food/Drug
Interactions
Continue
normal diet
Continue
normal diet
Side Effects
Pain, tenderness, hardness, or
warmth in the place where
ceftriaxone was injected, headache,
dizziness, sweating, flushing,
diarrhea, rash, bloody, watery stools,
fever, stomach cramps, bloating,
nausea and vomiting, heartburn,
chest pain
Nausea, vomiting, joint pain, pain
when swallowing, heartburn, white
patches in the mouth, blisters, rash,
hives, difficulty breathing or
swallowing, yellowing of the skin or
eyes, decreased urination
Continue
normal diet
Headache, dizziness, constipation,
diarrhea, hives, skin rash, itching,
swelling of the face, throat, tongue,
lips, eyes, hands, feet, ankles, or
lower legs, hoarseness, difficulty
breathing or swallowing
Continue
normal diet
Redness, pain, bruising, or sores at
the spot where heparin was injected;
hair loss, coughing up blood, vomit
that is bloody or looks like coffee
grounds, stool that contains bright
red blood or is black and tarry, blood
in urine, excessive tiredness,
discomfort in the arms, shoulder,
jaw, neck, or back; excessive
sweating, sudden severe headache,
lightheadedness or fainting, sudden
loss of balance or coordination,
sudden numbness or weakness of
the face, arm or leg, , sudden
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class of medications called
anticoagulants. It works by
decreasing the clotting ability of
the blood.
Zofran
(Ondansetron)
Used to prevent nausea and
vomiting caused by
chemotherapy and/or surgery. It
is in a class of medications called
serotonin 5-HT3 receptor
antagonists. It works by blocking
the action of serotonin, a natural
substance that may cause
nausea and vomiting.
Continue
normal diet
Used to treat colitis that may
occur after antibiotic treatment.
Vancomycin is in a class of
medications called glycopeptide
antibiotics. It works by killing
bacteria in the intestines. It will
not kill bacteria or treat
infections in any other part of
the body when taken by mouth.
Continuous Infusions:
D5 - 0.45 NaCl
Intravenously used to provide a
(dextrose and
source of hydration,
sodium
carbohydrate and electrolytes,
chloride)
indicated for parenteral
replenishment of fluid,
carbohydrate calories, and
sodium chloride. Contains
carbohydrate in the form of
dextrose which restores blood
glucose levels and provides
calories. Carbohydrate in the
form of dextrose may aid in
minimizing liver glycogen
depletion and exerts a proteinsparing action.
Norepinephrine Composed of alpha- adrenergic
Continue
normal diet
Vancomycin
confusion, or difficulty speaking or
understanding speech; difficulty
seeing in one or both eyes, itching
and burning, especially on the
bottoms of the feet; chills, fever,
hives, rash, wheezing, shortness of
breath, difficulty swallowing
Headache, constipation, diarrhea,
drowsiness, feeling cold or chills,
pain, burning, numbness, or tingling
in the hand or feet, fever, pain,
redness, swelling, warmth, or
burning in the place of injection,
rash, hives, itching, swelling of the
eyes, face, lips, tongue, throat,
hands, feet, ankles, or lower legs,
hoarseness, difficulty breathing or
swallowing, shortness of breath,
blurred vision or vision loss, fast,
slow or irregular heartbeat,
lightheadedness, fainting
upset stomach, hives, skin rash,
itching, difficulty breathing or
swallowing, redness of the skin
above the waist, pain and muscle
tightness of the chest and back,
unusual bleeding or bruising,
fainting, dizziness, blurred vision,
ringing in the ears
Continue
normal diet
Fever, infection at the site of
injection, venous thrombosis or
phlebitis extending from the site of
injection, extravasation and
hypervolemia.
Continue
Arrhythmias, bradycardia, peripheral
9
+ D5W
Milrinone
Dopamine
Furosemide
receptors (which increase
systemic blood pressure by
inducing arteriolar
vasoconstriction) and betaadrenergic receptors (which
stimulate heart rate, myocardial
contractility and coronary blood
flow. Used for restoration of BP
in controlling certain acute
hypotensive states.
Used for the short-term
treatment of acute
decompensated heart failure. In
the inotropes class of
medication, milrinone helps the
heart contract, which allows the
heart to pump blood more
effectively. Milrinone also
widens blood vessels. This makes
it easier for the heart to move
blood through arteries.
Important neurotransmitter that
regulates function in brain heart
kidneys and gut. An immediate
precursor of norepinephrine and
epinephrine. Used to treat shock
or symptomatic hypotension by
increasing myocardial
contractility and peripheral
dilation. Restores and preserves
blood flow to organs.
Used to reduce the swelling and
fluid retention caused by various
medical problems. It is also used
to treat high blood pressure. It
causes the kidneys to get rid of
unneeded water and salt from
the body into the urine.
Normal Diet
ischemia, anxiety, headache,
dyspnea, respiratory difficulty
Avoid
Angina, hypotension,
alcohol
supraventricular arrhythmia,
consumption. headache, anaphylaxis, atrial
fibrillation, bronchospasm,
hypokalemia, injection site reaction,
liver function abnormalities, MI, rash,
thrombocytopenia, torsade de
pointes, tremor, ventricular
fibrillation.
Continue
Normal diet.
Aberrant conduction, anginal pain,
atrial fibrillation, bradycardia, ectopic
beats, hyper-/hypotension,
palpitation, tachycardia,
vasoconstriction, ventricular
arrhythmia, anxiety, headache,
nausea, vomiting, polyuria, dyspnea
Doctor may
advise to
include foods
rich in
potassium,
magnesium,
and calcium
in diet, or
supplement
potassium.
Muscle cramps, weakness, dizziness,
confusion, thirst, upset stomach,
vomiting, blurred vision, headache,
restlessness, constipation, sore
throat, ringing in the ears, unusual
bleeding or bruising, loss of hearing,
severe rash with peeling skin,
difficulty breathing or swallowing,
excessive weight loss
6 ,7 & 8
Observable Physical and Psychological Changes in Patient
During the first nutrition assessment, MT was inappropriate for an interview because he
was intubated. By the second interview, he was “in and out” of consciousness. The third
10
assessment was the first time MT was alert and able to verbalize how he was feeling. This was
also the day that the physician gave the orders for MT to receive Ensure oral supplements.
Finally, on the fourth visit, MT was sitting up on his own, alert, eating soft foods and very
motivated to do whatever he could to expedite his recovery.
Treatment
MT was intubated as he underwent a number of tests as treatment for Sepsis. An Echo test
revealed MT’s heart was structurally normal with decreased left ventricular heart function.
Throughout the test, MT experienced tachycardia with varying rhythm as high as 102 beats per
minute. MT’s cardiovascular system showed concern for post-strep myocarditis with moderate
to severe decrease global ventricular systolic function but no pericardial effusion and normal
forward flow into the coronary arteries. His central nervous system was found to be normal
with no evidence of vegetation.
MT went through a procedure where a 22 gage IV was placed into his right radial vein for
the administration of IV medications and fluids. He was immediately started on intravenous
Dextrose in Normal Saline to replenish his fluids while also providing calories and energy. His
antibiotics were also administered intravenously.
When the physician believed it was medically feasible, MT was gradually tapered off of
Norepinephrine. Initially, the rate of which the Norepinephrine was decreased was too much
for MT to handle and his blood pressure began to drop drastically. The Norepinephrine was
raised and when his blood pressure returned to normal, it was decreased again at a slower rate
while his blood pressure was being carefully monitored. MT was extubated by the third
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nutrition assessment and his antibiotic treatment continued until his WBC count, CO2 and
Albumin levels were back within normal limits.
Medical Nutrition Therapy
Nutrition History
MT reported that at home, he does not follow any dietary restrictions. He consumes his
breakfast at school before his classes start. MT purchases lunch at school and brings his
afterschool snack from home to eat before basketball practice 4 times per week. Most dinners
are eaten at home around 6:30 pm and prepared by his mother. MT’s mother is also the main
purchaser of groceries in his household. Before going to bed, MT admits that he eats cookies as
an evening snack.
Analysis of Previous Diet
Below is an example of a typical eating day for MT.
Time
Meal
Food Item
6:30
Breakfast Sausage Biscuit
AM
2.5 oz Cantaloupe
4 oz apple juice
8 oz Chocolate Milk
1 slice Cheese Pizza on
11:45 Lunch
WW
1/2 cup Mashed Potatoes
Green Beans
4 oz Applesauce
8 oz Chocolate Milk
3:00
PBJ sandwich on white
Snack
PM
bread
2 oz sunflower seeds
Bottle of water
Calories CHO
(kcal)
(gm)
Protein Fat
(gm)
(gm)
Sodium
(mg)
Calcium Fiber
(mg)
(gm)
250
30
11
10.5
342
36
2
27
60
130
6.5
14
24
0
0
9
0
0
1
11
5
98
6
10
288
0.7
0
1
314
31
11
12
506
177
3
90
47
50
130
16
7
13
24
3
2
0
9
2.5
2
0
1
295
36
2
98
9
36
5
288
2
2
1
1
327
42
10
14
483
93
3
178
0
7
0
6
0
15
0
123
0
26
0
3
0
12
6:30
Dinner
PM
8:30
Snack
PM
Baked Chicken Breast
(skin on)
1 cup White Rice
1/2 cup Mixed Vegetables
Bottle of water
4 Chocolate Chips Ahoy
cookies
8 oz LF Milk
Totals for the day
191
0
29
8
385
14
0
188
25
0
35
5
0
4
1
0
4
0
0
233
45
0
17
23
0
1
2
0
190
26
2
9
118
10
1
102
12
2299 292.5
8
105
2
81
107
2887
305
1343
0
22.7
9 & 10
Current prescribed diet
Upon admission, MT was intubated and placed on a NPO diet in the Pediatric intensive
care unit (ICU) where he received Dextrose intravenously. Nutritional Services received a
consult for assessment because MT was NPO for more than 5 days. MT remained intubated and
NPO for the first two nutrition assessments. By the third nutrition follow up, MT was no longer
intubated and he was advanced to a clear liquid diet. After several hours of tolerating clear
liquids, such as gelatin, popsicles, broth and juice, MT was evaluated by a team of Health Care
professionals during the Pediatric ICU rounds where the Physician’s Assistant ordered Ensure
for MT via the Dietitian’s caloric recommendation. This meant that in order to meet his
estimated calorie requirements, MT was receiving 2 Ensures, 4 times per day for a total of 8 in
24 hours. By nutrition follow up number four, MT’s diet had been advanced to a mechanically
altered, soft diet.
Objectives of dietary treatment
The major objective of MT’s dietary treatment was to slowly progress him from NPO to
solid foods. This was initiated by first introducing the newly lucid MT to clear liquids. The
treatment objective of dietary improvement then changed from mere toleration to both
toleration and nourishment as the oral supplement Ensure was ordered. The ingredients of
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Ensure and their purpose were explained to both MT and his family. After one day of oral
supplementation without any major complications, MT was then advanced to soft solid foods.
Patient’s Physical and Psychological Response to Diet
When MT was conscious enough to eat, he was started on clear liquids. These items
were the first food items that MT had consumed in days. Once he showed easiness with clear
liquids, Ensure oral supplements were ordered. MT selected vanilla as his flavor of choice with
the Ensure. Because he was receiving them so many times per day, MT quickly grew tired of
having one particular flavor so he tried both strawberry and chocolate before his diet was
advanced beyond liquids. When MT was asked about how he was complying with the Ensures,
he responded, “I am drinking them because I know I need to but I wouldn’t want to live off of
these.” MT expressed his desire to try solid foods again as soon as possible to get back to what
he considered his normal diet. He was advised to take the advancement of his diet slowly.
List nutrition-related problems with supporting evidence
During the four visits, MT’s nutrition related problem remained the same. The nutrition
diagnosis is as follows:
Inadequate Protein Energy related to inability to consume adequate protein and energy as
evidenced by energy intake from diet less than estimated needs and recovering status.
Evaluation of Present Nutritional Status
According to the diet analysis table above, MT was previously meeting his estimated
calorie needs although in some cases, not from the most nutritive of sources. Upon entry to the
hospital, MT’s lab values indicated serious dehydration. MT was admitted to the hospital at
60.6 kg. Once MT was placed on IV fluids, he weighed in at 67 kg. This means that with the
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addition of adequate fluids, MT gained approximately 6 kg (13 pounds) of body weight. 67 kg is
the weight that was used for medication dosages and for caloric requirement estimations.
Kcal/Protein Guidelines
In adolescent males, the estimated energy requirements (EERs) can be used to estimate
caloric requirements. To compensate for the great variation in growth rates for this age group,
EERs are calculated using age, sex, height, weight and physical activity level. 2
Nutritional needs are often substantially increased in sepsis due to the magnitude of the
ailment. Septic patients also have significant drains on their nutrient resources with bacterial
and viral utilization of available nutrients for their own metabolism and reproduction. Daily
energy requirements in metabolic stress may be calculated by using 25-30 calories per kilogram
of body weight. 1&2
During adolescence, protein requirements vary with degree of maturation. Sepsis is a
distressing factor that increases the protein requirements above the DRI to 1.2-2 grams per
kilogram of body weight depending on the degree of illness. Administration of excessive
amounts of protein will not decrease the characteristic net negative nitrogen balance seen in
hyper-metabolic patients.1&2
Below is a chart of how MT’s needs were clinically calculated during his hospital stay from
February 4th through February 7th.
Kcal calculations
EER for active 16 year old male =
2449 kcal/day
Protein calculations for adjusted
body weight
90 gm/day
1.5 g/kg admit weight
Fluid requirements
2400-2420 ml/day or per
Physician
Mifflin REE = 1496 x Activity Factor
1.2-1.6 = 1794-2449 kcal/day
15
Need for Vitamin/Mineral Supplementation and the Patient’s Nutrition Education Process
During his recovery, MT was prescribed the oral supplement Ensure to provide energy
from carbohydrates, protein, fat, vitamins and minerals. This order was made during his
transition from clear liquids to solid foods. The components of Ensure as well as the function
and importance in the diet progression were clarified to MT and his family. The explanation
was acknowledged by MT and no type of barrier to learning was identified.
General Conditions upon Discharge and Plan for Follow-Up
MT was not cleared for discharge during the time of the case study. The conditions upon
which he would be discharged included consistent acceptance of solid foods. Hopefully, this
was a one-time experience for MT. Unquestionably he will never look at bacterial infections the
same, especially sore throats. Chances are he will be cautious when it comes to protecting
himself from bacteria in the future by giving it a more serious thought.
Prognosis
Receiving multiple Ensures daily was a visual, motivating factor that encouraged MT to
succeed in developing his diet. Also, it was explained to MT that if he was unable to meet his
needs by mouth, tube feeding would be the next viable means of sustenance. MT clearly
expressed his dislike for the oral supplement Ensure. Though reluctant, he did consume them
as prescribed while he was in the hospital. Seeing how many of the supplemental beverages
were required to meet his estimated calorie needs put into perspective how closely nutrition
was correlated to his recovery. Once he was advanced to a mechanically altered, soft diet, he
also conveyed his dislike of the soft food options available in the hospital. Again, although
reluctant, he consumed the soft foods little by little so not to have to resort to the alternative
16
means of feeding. With the hospital room service, MT was able to call to place a food order of
his personal food selections whenever he felt hungry.
Summary
I have learned so much valuable information from this circumstance. Prior to this case
study, I only knew sepsis to be a serious illness that was to be avoided if at all possible. I had no
idea that something as common as strep throat could evolve into a severe, and in some cases,
life threatening hyper-metabolic response. Unfortunately, sepsis cannot always be avoided.
Infections can take off so quickly, before one suspects, it can happen. Learning about the
severity of sepsis has caused me to give sore throats or any minor bacterial infection a second
thought. I will not hesitate to seek timely treatment and I will encourage others to do so as
well.
17
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Images
1. http://www.pathologyatlas.net/news/what-helps-a-sore-throat/
2. http://www.strepthroatdoctor.org/pictures-of-strep-throat/
3. https://www.nrc-cnrc.gc.ca/eng/dimensions/issue7/superbug.html
4. http://www.kidsdata.org/blog/?paged=3
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