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Scarlet Fever

Fevers Scarlet

Scarlet fever (Scarlatina) is an acute infectious disease caused by β-hemolytic streptococci. It predominantly occurs in children aged 3 to 10 years, though it can also occur in older children and adults. Transmission occurs usually by droplet infection via the respiratory tract.


Presentation

This disease presents with a sore throat after which fever sets in. There is redness and swelling of the tongue with spots called ‘Strawberry tongue’. Small red spots may also be present inside the oral cavity, particularly on the soft palate called Forchheimer spots.

Scarlet fever is classically manifested by a punctuate erythematous rash that is most prominent over the trunk and inner aspects of the arms and legs [8]. The rash is a characteristic feature of scarlet fever. It presents within 12-72 hours after the fever sets in and appears as a fine, rough, red coloured rash that begins in the trunk and armpits and then progresses over to the face and the rest of the body. It typically blanches under pressure and when present on the face, it presents with erythema of the face leaving a pale circular area around the mouth, which is called circumoral pallor. This rash is characteristically prominent on skin folds, called Pastia lines.

Fever
  • Scarlet fever has no vaccine available.[symptoma.com]
  • Children under 15 years of age were the most susceptible to scarlet fever.[ncbi.nlm.nih.gov]
  • Multivariate analysis indicated associations of ssa, speA and speC with scarlet fever. In nonoutbreak conditions, scarlet fever is caused by a number of distinct genetic lineages.[ncbi.nlm.nih.gov]
  • fever outbreaks in Hong Kong (n 134) and the United Kingdom (n 63).[ncbi.nlm.nih.gov]
  • […] of scarlet fever incidence in Beijing districts from 2013 to 2014.[ncbi.nlm.nih.gov]
Chills
  • […] recurrens Recurrent aphthous ulcer Stomatitis herpetiformis rash A38.9 Disease, diseased - see also Syndrome Fothergill's scarlatina anginosa A38.9 Febris, febrile - see also Fever rubra A38.9 Fever (inanition) (of unknown origin) (persistent) (with chills[icd10data.com]
  • Symptoms may include: Fever Sore throat Chills Headache Vomiting Stomachache Coated white tongue Strawberry-like appearance of the tongue The rash begins approximately one to two days after the initial infection.[chop.edu]
  • Symptoms Fever Peaks on Day 2 Returns to normal on Day 5-7 Chills Headache Vomiting Pharyngitis V.[fpnotebook.com]
  • Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Exams and Tests Physical examination[nicklauschildrens.org]
Malaise
  • Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Exams and Tests Physical examination[nicklauschildrens.org]
  • Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Your health care provider may[medlineplus.gov]
  • Other symptoms include chills, aches, loss of appetite, swollen glands, malaise, nausea, stomach ache and vomiting . The telltale rash commonly breaks out on the second day and typically lasts about two to five days.[babycenter.com]
  • Scarlet fever usually starts with a sudden fever associated with sore throat, swollen neck glands, headache, nausea, vomiting, loss of appetite, swollen and red strawberry tongue, abdominal pain, body aches, and malaise .[dermnetnz.org]
  • Also called scarlatina . observations Signs and symptoms appear 1 to 3 days after exposure to the agent, starting with an abrupt high fever, chills, tachycardia, nausea, vomiting, headache, abdominal pain, malaise, and a sore throat.[medical-dictionary.thefreedictionary.com]
Vomiting
  • There also may be chills, vomiting, or abdominal pain. The tongue may have a whitish coating and appear swollen. It may also have a “strawberry”-like (red and bumpy) appearance.[cdc.gov]
  • The most common symptoms of this Streptococcus A infection are the sudden onset of a sore throat , tender and swollen lymph glands in the neck, a high fever , vomiting , and a characteristic rash covering the whole body.[raisingchildren.net.au]
  • Some patients will have whitish coating on the tongue or the throat and may have swollen lymph nodes glands, headache , abdominal pain or discomfort resulting in nausea and vomiting , and/or body aches.[medicinenet.com]
  • Headache, vomiting and abdominal pain may also occur. The tongue may have a distinctive "strawberry"-like (red and bumpy) appearance.[chp.gov.hk]
Nausea
  • Some patients will have whitish coating on the tongue or the throat and may have swollen lymph nodes glands, headache , abdominal pain or discomfort resulting in nausea and vomiting , and/or body aches.[medicinenet.com]
  • Other symptoms that appear before the rash, especially in children, may include general body aches, headache, stomachache, nausea, vomiting, or listlessness.[northshore.org]
  • Symptoms include a sore throat, headache, fever, nausea and vomiting, followed by a fine red rash which typically first appears on the chest and stomach, rapidly spreading to other parts of the body.[valeofglamorgan.gov.uk]
  • Other less common symptoms include headache, nausea, vomiting, and body aches. Complications as a result of untreated scarlet fever are rare and include rheumatic heart disease and kidney damage, also known as post-streptococcal glomerulonephritis.[canada.ca]
Abdominal Pain
  • There also may be chills, vomiting, or abdominal pain. The tongue may have a whitish coating and appear swollen. It may also have a “strawberry”-like (red and bumpy) appearance.[cdc.gov]
  • Headache, vomiting and abdominal pain may also occur. The tongue may have a distinctive "strawberry"-like (red and bumpy) appearance.[chp.gov.hk]
  • He may also have a white coated, then reddened, tongue, and mild abdominal pain. Treatment Call your pediatrician whenever your child complains of a sore throat, especially when a rash or fever also is present.[healthychildren.org]
  • Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Exams and Tests Physical examination[nicklauschildrens.org]
  • Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Your health care provider may[medlineplus.gov]
Strawberry Tongue
  • By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with swollen papillae (red strawberry tongue). White strawberry tongue Red strawberry tongue Last revised 11/27/13 1996-2013 Neal Chamberlain . All rights reserved.[atsu.edu]
  • There is redness and swelling of the tongue with spots called ‘Strawberry tongue’. Small red spots may also be present inside the oral cavity, particularly on the soft palate called Forchheimer spots.[symptoma.com]
  • During the first few days of the infection, a white coating with a bright red tongue (white strawberry tongue) is prevalent. The white membrane falls off leaving a shiny, bright red tongue (red strawberry tongue).[aocd.org]
  • The chief diagnostic signs of scarlet fever are the characteristic rash, which spares the palms and soles of the feet, and the presence of a strawberry tongue in children. Strawberry tongue is rarely seen in adults.[healthofchildren.com]
Palatal Petechiae
  • Signs Forehead and cheeks appear flushed Circumoral pallor Pharyngitis Tonsil s are hyperemic and edematous, with exudate Throat is inflamed and covered by a membrane Palatal Petechiae may be present Strawberry Tongue Fine Papule s on Tongue surface Tongue[fpnotebook.com]
  • The throat will be a bright red , but sometimes may just have red spots on the back of the throat or palate, called palatal petechiae . Usually, but not always, a white phlegmy substance (called exudate), can be seen on the tonsils.[ourmed.org]
Tonsillar Exudate
  • There was fever in 89% of the processes (95% CI: 84-94%), with a temperature of 38 C in 73% (95% CI: 65-80%), enlarged lymph nodes in 70% (95% CI: 58-82%), absence of cough in 73% (95% CI: 65-80%), and tonsillar exudate in only 24% (95% CI: 17-31%).[ncbi.nlm.nih.gov]
Flushing
  • Essential facts Scarlet fever is characterised by a rash that usually accompanies a sore throat and flushed cheeks. It is mainly a childhood illness.[ncbi.nlm.nih.gov]
  • Peeling Peeling The sandpapery rash does not usually occur on the face, the patient's forehead and cheeks appears red and flushed. In addition to this flushed appearance, there is usually a pale area around their mouth (circumoral pallor).[atsu.edu]
  • The strain of streptococcus that causes scarlet fever, unlike the one that causes most strep throats, produces an erythrogenic toxin, which causes the skin to flush.[healthofchildren.com]
  • Symptoms include a rash, a sore throat, flushed cheeks and swollen tongue. Scarlet fever is caused by Streptococcus pyogenes or group A streptococci (GAS) bacteria. Occasionally these bacteria can cause severe and life-threatening diseases.[gov.uk]
  • Flushed face. The face may appear flushed with a pale ring around the mouth. Strawberry tongue. The tongue generally looks red and bumpy, and it's often covered with a white coating early in the disease.[mayoclinic.org]
Petechiae
  • Signs Forehead and cheeks appear flushed Circumoral pallor Pharyngitis Tonsil s are hyperemic and edematous, with exudate Throat is inflamed and covered by a membrane Palatal Petechiae may be present Strawberry Tongue Fine Papule s on Tongue surface Tongue[fpnotebook.com]
  • As mentioned above, a non-blanching rash, purpura (large purple patches), and petechiae (pinpoint red non-blanching dots), all suggest meningococcemia instead of scarlet fever.[ourmed.org]
  • The rash lasts for several days but after a few days of becoming generalised it may appear more prominent in skin creases, with confluent petechiae or lines (capillary fragility).[patient.info]
  • […] pharyngitis by Streptococcus group A–which produces an erythrogenic toxin, consisting of an oral enanthema–'raspberry' tongue, 'strawberry' tongue, generalized blanching erythema–sparing the palmoplantar region and mouth with circumoral pallor and linear petechiae–Pastia's[medical-dictionary.thefreedictionary.com]
  • […] coating) the whiteness disappears while the red and enlarged papillae give it the "red strawberry" appearance. [7] Note that this involvement of the tongue is a part of the rash which is characteristic of scarlet fever. [8] Pastia's lines [9] Lines of petechiae[en.wikipedia.org]
Eruptions
  • The clinical picture mimicked that of drug eruption after treatment of cellulitis with antibiotics.[ncbi.nlm.nih.gov]
  • 2016 2017 2018 2019 Billable/Specific Code Type 1 Excludes specified type of rash- code to condition vesicular eruption ( R23.8 ) canker A38.9 scarlet A38.9 Scarlatina (anginosa) (maligna) A38.9 Scarlet fever A38.9 (albuminuria) (angina) ICD-10-CM Codes[icd10data.com]
  • A rapidly erupting rash appears 1 to 2 days after the onset of the sore throat. The rash displays as pinhead-size red lesions, which rapidly cover the body except for the face.[medical-dictionary.thefreedictionary.com]
  • Pathophysiology As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness.[emedicine.medscape.com]
  • […] addition to a fever, indicative of a viral process. [14] Allergic or contact dermatitis : The erythematous appearance of the skin will be in a more localized distribution rather than the diffuse and generalized rash seen in Scarlet Fever. [12] Drug eruption[en.wikipedia.org]
Exanthema
  • (By Afag Azizova (own work) via Wikimedia Commons) Differential diagnosis [ 9 , 12 ] Other viral exanthema: Erythema infectosum (or fifth disease) Measles Rubella Roseola Other nonspecific viruses Infectious mononucleosis Toxic shock syndrome Kawasaki[patient.info]
Circumoral Pallor
  • In addition to this flushed appearance, there is usually a pale area around their mouth (circumoral pallor). Circumoral Pallor Another finding is dark, hyperpigmented areas on the skin, especially in skin creases.[atsu.edu]
  • His physical exam is notable for a bright red tongue, grey-white tonsilar exudates, a blanching erythematous "sandpaper-like" rash on his trunk (Figure A), and circumoral pallor (Figure B).[medbullets.com]
  • Signs Forehead and cheeks appear flushed Circumoral pallor Pharyngitis Tonsil s are hyperemic and edematous, with exudate Throat is inflamed and covered by a membrane Palatal Petechiae may be present Strawberry Tongue Fine Papule s on Tongue surface Tongue[fpnotebook.com]
  • It typically blanches under pressure and when present on the face, it presents with erythema of the face leaving a pale circular area around the mouth, which is called circumoral pallor.[symptoma.com]
  • The face is flushed but a pale zone is left around the mouth (circumoral pallor). The tongue has a white coating with red spots. As the rash fades there is skin peeling.[medical-dictionary.thefreedictionary.com]
Epistaxis
  • Skin hemorrhaging, hematuria, and epistaxis occurred in patients with the hemorrhagic form of scarlet fever. These symptoms typically occurred within the first two to three days of the illness.[uspharmacist.com]
Headache
  • Early warning signs include sore throat, headache and fever, flushed cheeks and swollen red 'strawberry' tongue with the characteristic pinkish/red sandpapery rash.[dailymail.co.uk]
  • The symptoms of scarlet fever begin with a sore throat, a fever of 101 to 104 degrees Fahrenheit (38.2–40 degrees Celsius), and headache. This is followed within twenty-four hours by a red rash covering the trunk, arms, and legs.[healthychildren.org]
  • -Headache. -Nausea or vomiting. -Body aches and pain. -A general feeling of unwell. -Loss of appetite. -Swollen neck glands.[irishhealth.com]
  • Symptoms and signs of this infection include sore throat, headache, enlarged tonsils, fever, and chills. Nausea, vomiting, and abdominal pain can accompany these symptoms.[medicinenet.com]
Febrile Convulsions
  • Using paracetamol in children or babies does not reduce the risk of febrile convulsions . You should dress them in clothes that are appropriate for the outside or inside temperature.[patient.info]

Workup

Laboratory tests

  • Complete blood count
  • ESR
  • Urinalysis
  • Throat culture: According to the American Heart Association, signs of group A streptococci (GAS) are always found in throat cultures in acute infections [9]. 
  • Anti-deoxyribonuclease B antibody titres
  • Anti-streptolysin-O titres

Imaging 

Imaging studies are not required to diagnose scarlet fever.

Test results

On the basis of results of throat culture and antibody testing, a diagnosis can be made.

Treatment

Most scientists recommend penicillins, like benzylpenicillin and phenoxymethylpenicllin as drugs of first choice for effective treatment of Streptococcus tonsillopharyngitis and scarlet fever [3]. Erythromycin may be considered as an alternative drug if patients are resistant or allergic to penicillin or 1st generation cephalosporins [10]. A 10 day course of the antibiotics is generally sufficient to treat the infection. Patients should also be kept isolated during the course of the disease to prevent transmission.

Prognosis

Scarlet fever has an excellent prognosis. The fever persists for 3 to 6 days and the rash begins to desquamate and peel off on its own, fading after around 6 days. The disease is completely eradicated from the body with the help of a 10 day course of antibiotics.

Etiology

Scarlet fever is considered an infectious, toxin-mediated disease whose pathogenicity depends upon production of specific exotoxins [2].

Causative agent

The main causative agent of scarlet fever is a gram positive bacterium called Streptococcus pyogenes, which belongs to the β-hemolytic group A streptococci, and is a natural colonizer of the human nasopharynx and oral cavity. S. pyogenes causes the widest range of infectious diseases in humans among all known bacterial pathogens [3]. Other members of the group A streptococci are also implicated in causing scarlet fever.

Transmission

There has been a confirmed outbreak of person-to-person transmitted scarlet fever, and the main risk factor was having a relative with tonsillitis [4]. Transmission is mainly air borne; via inhaled aerosol droplets containing the infectious agents, but the illness can be also be food borne.

Epidemiology

Incidence

Increases in scarlet fever above usual seasonal levels are currently being seen across the United Kingdom [5]. Worldwide, around 10% of people are likely to get a throat infection from group A streptococci, and only 10% of these people are likely to develop scarlet fever.

Age

Scarlet fever is a rare disease in adult patients [6]. It typically affects young children between 5-15 years. Usually as the child reaches 10 years of age and above, antibodies to GAS strains are developed and circulated in the body, making the child fairly immune to further infections by the same bacteria.

Sex

This disease affects males and females equally.

Sex distribution
Age distribution

Pathophysiology

The infective organisms may be inhaled or ingested, and after infection by a strain of group A streptococci, an incubation period of 1 to 4 days takes place. The bacteria produce pyrogenic toxins that cause the characteristic rash and fever. According to a retrospective study conducted in Taiwan, the frequencies of pyrogenic exotoxin genes were 9.5% for speA, 81.0% for speB, 4.8% for speC, and 71.4% for speF in isolates from patients of scarlet fever [7]. Inflammatory process begins which contributes to the redness of the rash. Patients are infective both during this as well as the subclinical period.

Prevention

Scarlet fever has no vaccine available. Because of the wide distribution of S. pyogenes in the general population and the lack of an effective vaccine, possibilities for prevention allowing a suitable protection for diseases due to S. pyogenes are very limited [3]. 

Summary

Scarlet fever is one of a variety of diseases caused by group A streptococcus (GAS) [1]. It may be endemic, epidemic or sporadic and indeed many outbursts throughout the world have been reported in the past years. Scarlet fever is usually associated with pharyngitis which is the primary mode of illness by species of the group A streptococci, and often occurs after a throat infection. Although it is now perfectly treatable with the help of antibiotics that target gram positive bacteria, scarlet fever was a source of high mortality in the past. 

Patient Information

Definition

Scarlet fever is a streptococcal disease characterized by a skin rash in children. It can be endemic, epidemic or sporadic [3].

Cause

It is caused by bacteria belonging to group A Streptococci, which are gram positive strains and many are normally present in the nasopharynx.

Signs and symptoms

Scarlet fever begins with a sore throat which then progresses to a fever and a characteristic rash all over the body. The tongue becomes bright red and is called strawberry tongue. The infection persists for 3-6 days and the rash begins to peel off after 5-6 days.

Diagnosis

Diagnosis can be made clinically if characteristic signs are present. Throat culture is considered gold standard for diagnosis and antibody testing can also aid the diagnosis.

Treatment

Treatment is a course of antibiotics for 8-10 days along with bed rest and avoidance of public places to reduce the chances of transmission.

References

Article

  1. Yang P, Peng X, Zhang D, Wu S, Liu Y, Cui S, Lu G, Duan W, Shi W, Liu S, Li J, Wang Q. Characteristics of group A Streptococcus strains circulating during scarlet fever epidemic, Beijing, China, 2011. Emerg Infect Dis. 2013 Jun;19(6):909-15. 
  2. Silva-Costa C, Carriço JA, Ramirez M, Melo-Cristino J. Scarlet fever is caused by a limited number of Streptococcus pyogenes lineages and is associated with the exotoxin genes ssa, speA and speC. Pediatr Infect Dis J. 2014 Mar;33(3):306-10. 
  3. Stock I. Streptococcus pyogenes--much more than the aetiological agent of scarlet fever. [Article in German]. Med Monatsschr Pharm. 2009 Nov;32(11):408-16. 
  4. Fernández-Prada M, Martínez-Diz S, Colina López A, Almagro Nievas D, Martínez Romero B, Huertas Martínez J. Scarlet fever outbreak in a public school in Granada in 2012. An Pediatr (Barc). 2014 Apr;80(4):249-53.
  5. Guy R, Williams C, Irvine N, Reynolds A, Coelho J, Saliba V, Thomas D, Doherty L, Chalker V, von Wissmann B, Chand M, Efstratiou A, Ramsay M, Lamagni T. Increase in scarlet fever notifications in the United Kingdom, 2013/2014. Uro Surveill. 2014 Mar 27;19(12):20749. 
  6. Sandrini J, Beucher AB, Kouatchet A, Lavigne C. [Scarlet fever with multisystem organ failure and hypertrophic gastritis]. Rev Med Interne. May 2009;30(5):456-9
  7. Wu PC, Lo WT, Chen SJ, Wang CC. Molecular characterization of Group A streptococcal isolates causing scarlet fever and pharyngitis among young children: a retrospective study from a northern Taiwan medical center. J Microbiol Immunol Infect. 2014 Aug;47(4):304-10. 
  8. Robbins and Cotran. Pathologic Basis of Disease. 8th ed. Philadelphia, Pa: Saunders Elsevier, 2010. ISBN 978-1-4160-3121-5
  9. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51
  10. Bass JW. Antibiotic management of group A streptococcal pharyngotonsillitis. Pediatr Infect Dis J. Oct 1991;10(10 Suppl):S43-9 

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Last updated: 2018-06-22 12:16