Scarlet Fever Differential Diagnoses
- Author: Bahman Sotoodian, MD; Chief Editor: William D James, MD more...
The overwhelming majority of cases of scarlet fever are caused by group A beta-hemolytic streptococci (GABHS). Other bacteria can cause a pharyngitis and similar rash, such as Staphylococcus aureus, Haemophilus influenzae, Arcanobacterium haemolyticum, and Clostridium species. The differential diagnosis includes other causes of fever accompanied by erythematous eruptions. Recurrent cases of scarlet fever have been reported from reinfection with strains unrelated to Streptococcus pyogenes.
The cutaneous eruption of fifth disease may be confused with that of scarlet fever, but the affected child is usually well and afebrile.
Rubella and rubeola may appear similar, but the presence of conjunctivitis, purulent rhinitis, and cough are helpful clues to the diagnosis of rubeola. In addition, the eruption of rubeola usually begins behind the ears and on the scalp and forehead, not on the torso. Rubella typically begins on the head and face.
Other viral exanthemata, such as those caused by Epstein-Barr virus (infectious mononucleosis), enterovirus, HIV infection, and Streptobacillus moniliformis infection (rat bite fever), may also have to be considered.
Other bacteria-associated syndromes with cutaneous eruptions (eg, toxic shock syndrome, secondary syphilis) may appear similar to scarlet fever, but the presence of vasomotor instability and ischemic necrosis of digits in the former and palmoplantar involvement with positive serology in the latter should suffice to differentiate them from scarlet fever.
Other problems to be considered include the following:
Enteroviral infection and nonspecific viral infection
Epstein-Barr virus (infectious mononucleosis)
Juvenile rheumatoid arthritis
Plant allergic reactions
S moniliformis infection (rat bite fever)
Guttate psoriasis: Streptococcal infection is known to precipitate guttate psoriasis and may also cause scarlet fever. The 2 are easily distinguished, as the flexural erythema with sandpaperlike texture and petechiae of scarlet fever are very different from the disseminated, round, erythematous lesions with silver scale of guttate psoriasis.
Recurrent toxin-mediated perineal erythema
Dong H, Xu G, Li S, Song Q, Liu S, Lin H, et al. Beta-haemolytic group A streptococci emm75 carrying altered pyrogenic exotoxin A linked to scarlet fever in adults. J Infect. 2008 Apr. 56(4):261-7. [Medline].
Yang SG, Dong HJ, Li FR, Xie SY, Cao HC, Xia SC, et al. Report and analysis of a scarlet fever outbreak among adults through food-borne transmission in China. J Infect. 2007 Nov. 55(5):419-24. [Medline].
Leslie DL, Kozma L, Martin A, Landeros A, Katsovich L, King RA, et al. Neuropsychiatric disorders associated with streptococcal infection: a case-control study among privately insured children. J Am Acad Child Adolesc Psychiatry. 2008 Oct. 47(10):1166-72. [Medline]. [Full Text].
Sandrini J, Beucher AB, Kouatchet A, Lavigne C. [Scarlet fever with multisystem organ failure and hypertrophic gastritis]. Rev Med Interne. 2009 May. 30(5):456-9. [Medline].
Gómez-Carrasco JA, Lassaletta A, Ruano D. [Acute hepatitis may form part of scarlet fever]. An Pediatr (Barc). 2004 Apr. 60(4):382-3. [Medline].
Güven A. Hepatitis and hematuria in scarlet fever. Indian J Pediatr. 2002 Nov. 69(11):985-6. [Medline].
Lau SK, Woo PC, Yuen KY. Toxic scarlet fever complicating cellulitis: early clinical diagnosis is crucial to prevent a fatal outcome. New Microbiol. 2004 Apr. 27(2):203-6. [Medline].
Finnish Medical Society Duodecim. Sore throat and tonsillitis. EBM Guidelines. Evidence-Based Medicine. Feb 2 2007Helsinki, Finland: Wiley Interscience. John Wiley & Sons. [Full Text].
Reddy UP, Albini TA, Banta JT, Davis JL. Post-streptococcal vasculitis. Ocul Immunol Inflamm. 2008 Jan-Feb. 16(1):35-6. [Medline].
Wilson PF, Wannemuehler TJ, Matt BH. Invasive group A Streptococcus resulting in sepsis and abdominal wall abscess after adenotonsillectomy. Laryngoscope. 2015 May. 125 (5):1230-2. [Medline].
Gaston DA, Zurowski SM. Arcanobacterium haemolyticum pharyngitis and exanthem. Three case reports and literature review. Arch Dermatol. 1996 Jan. 132(1):61-4. [Medline].
Sanz JC, Bascones Mde L, Martín F, Sáez-Nieto JA. [Recurrent scarlet fever due to recent reinfection caused by strains unrelated to Streptococcus pyogenes]. Enferm Infecc Microbiol Clin. 2005 Jun-Jul. 23(6):388-9. [Medline].
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. 2009 Mar 24. 119(11):1541-51. [Medline].
Bass JW. Antibiotic management of group A streptococcal pharyngotonsillitis. Pediatr Infect Dis J. 1991 Oct. 10(10 Suppl):S43-9. [Medline].
Derrick CW, Dillon HC. Erythromycin therapy for streptococcal pharyngitis. Am J Dis Child. 1976 Feb. 130(2):175-8. [Medline].
Stock I. [Streptococcus pyogenes--much more than the aetiological agent of scarlet fever]. Med Monatsschr Pharm. 2009 Nov. 32(11):408-16; quiz 417-8. [Medline].