Scarlet Fever in Emergency Medicine Clinical Presentation

  • Author: Jerry Balentine, DO; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Mar 19, 2010
 

History

  • Scarlet fever generally has a 1- to 4-day incubation period.
  • Emergence of the illness tends to be abrupt, usually heralded by sudden onset of fever associated with sore throat, headache, nausea, vomiting, abdominal pain, myalgias, and malaise.
  • The characteristic rash appears 12-48 hours after onset of fever.
  • In the untreated patient, fever peaks by the second day (temperature as high as 103-104°F) and gradually returns to normal in 5-7 days.
  • Fever abates within 12-24 hours after initiation of antibiotic therapy.
  • Recent history of exposure to another individual with a "strep" infection may aid in the diagnosis.
Next

Physical

  • Exudative tonsillitis preceding scarlet fever often is accompanied by erythematous oral mucous membranes, along with petechiae and punctate red macules on the hard and soft palate and uvula (ie, Forchheimer spots).
  • On day 1 or 2, a white coating covers the dorsum of the tongue with reddened papillae projecting through, giving rise to the white strawberry tongue. This white coating is shown in the image below. The exudative pharyngitis typical of scarlet feverThe exudative pharyngitis typical of scarlet fever. Although the tongue is somewhat out of focus, the whitish coating observed early in scarlet fever is visible.
  • By day 4 or 5, the white coating disappears, revealing the representative raspberry tongue.
  • Generally, the rash develops 12-48 hours after the onset of fever, first appearing as erythematous patches below the ears, chest, and axilla.
    • Dissemination to the trunk and extremities occurs over 24 hours.
    • Typically, the rash consists of scarlet macules over generalized erythema (boiled lobster appearance).
    • As the skin lesions evolve and become more diffuse, they turn punctate and resemble a sunburn with goose pimples.
    • Numerous punctate lesions the size of pinheads give the skin a rough sandpaperlike texture.
    • Lesions tend to be accentuated in the skin folds, particularly in the region of the neck, axilla, antecubital fossae, and inguinal and popliteal creases.
    • Rupture of fragile capillaries at these sites displays linear arrays of petechiae (ie, Pastia lines) that may persist for 1-2 days after resolution of the generalized rash.
  • Another distinctive facial finding is circumoral pallor.
  • In severe disease, small vesicular lesions termed miliary sudamina may appear on the abdomen, hands, and feet.
  • Mitigation of the exanthem occurs in approximately 1 week.
    • Desquamation, shown in the image below, one of the most distinctive features of scarlet fever, begins 7-10 days after resolution of the rash and may continue up to 6 weeks. Desquamation of the palms is a frequently observedDesquamation of the palms is a frequently observed self-limited manifestation of scarlet fever present in the healing period following resolution of the infection and acute eruption.
    • Peeling of the skin is most prominent in the axilla, groin, and tips of the fingers and toes.
    • Extent and duration of desquamation is directly proportional to initial intensity of the rash.
Previous
Next

Causes

Infection of group A beta-hemolytic streptococci causes scarlet fever.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel P Lombardi, DO  Clinical Assistant Professor, New York College of Osteopathic Medicine and Clinical Instructor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Program Director, Department of Emergency Medicine, Saint Barnabas Hospital

Daniel P Lombardi, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph A Salomone III, MD  Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Weiss, MD, DTM&H  Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

  1. 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. [Medline].

  2. [Guideline] 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. [Medline]. [Full Text].

  3. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. Jul 2004;17(3):571-80, table of contents. [Medline].

  4. Bass JW. Antibiotic management of group A streptococcal pharyngotonsillitis. Pediatr Infect Dis J. Oct 1991;10(10 Suppl):S43-9. [Medline].

  5. Derrick CW, Dillon HC. Erythromycin therapy for streptococcal pharyngitis. Am J Dis Child. Feb 1976;130(2):175-8. [Medline].

  6. Stock I. [Streptococcus pyogenes--much more than the aetiological agent of scarlet fever]. Med Monatsschr Pharm. Nov 2009;32(11):408-16; quiz 417-8. [Medline].

  7. Gidaris D, Zafeiriou D, Mavridis P, Gombakis N. Scarlet Fever and hepatitis: a case report. Hippokratia. Jul 2008;12(3):186-7. [Medline].

  8. Reddy UP, Albini TA, Banta JT, Davis JL. Post-streptococcal vasculitis. Ocul Immunol Inflamm. Jan-Feb 2008;16(1):35-6. [Medline].

  9. 2006 Report of the Committee on Infectious Diseases. Summaries of Infectious Diseases. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book. 27th ed. American Academy of Pediatrics; 2006:610-618.

  10. Bialecki C, Feder HM Jr, Grant-Kels JM. The six classic childhood exanthems: a review and update. J Am Acad Dermatol. Nov 1989;21(5 Pt 1):891-903. [Medline].

  11. Burns JC, Kushner HI, Bastian JF, et al. Kawasaki disease: A brief history. Pediatrics. Aug 2000;106(2):E27. [Medline].

  12. [Guideline] Dajani A, Taubert K, Ferrieri P, Peter G, Shulman S. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association. Pediatrics. Oct 1995;96(4 Pt 1):758-64. [Medline].

  13. Danjani AS, Bisno AL, Chung KJ, et al. Prevention of rheumatic fever. A statement for health professionals by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association. Circulation. Oct 1988;78(4):1082-6. [Medline].

  14. Del Castillo LD, Macaset T, Olsen J. Group A streptococcal pharyngitis and scarlatiniform rash in an 8-week-old infant. Am J Emerg Med. Mar 2000;18(2):233-4. [Medline].

  15. Duncan SR, Scott S, Duncan CJ. Modelling the dynamics of scarlet fever epidemics in the 19th century. Eur J Epidemiol. 2000;16(7):619-26. [Medline].

  16. Facklam RR. Specificity study of kits for detection of group A streptococci directly from throat swabs. J Clin Microbiol. Mar 1987;25(3):504-8. [Medline].

  17. Hoebe CJ, Wagenvoort JH, Schellekens JF. [An outbreak of scarlet fever, impetigo and pharyngitis caused by the same Streptococcus pyogenes type T4M4 in a primary school]. Ned Tijdschr Geneeskd. Nov 4 2000;144(45):2148-52. [Medline].

  18. Hubalek Z. North Atlantic weather oscillation and human infectious diseases in the Czech Republic, 1951-2003. Eur J Epidemiol. 2005;20(3):263-70. [Medline].

  19. Kaplan EL, Krugman S. Streptococcal infection. Infect Dis Child. 1992;474-86.

  20. Katz AR, Morens DM. Severe streptococcal infections in historical perspective. Clin Infect Dis. Jan 1992;14(1):298-307. [Medline].

  21. Quinn RW. Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever. Rev Infect Dis. Nov-Dec 1989;11(6):928-53. [Medline].

  22. Richardson M, Elliman D, Maguire H, Simpson J, Nicoll A. Evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and preschools. Pediatr Infect Dis J. Apr 2001;20(4):380-91. [Medline].

  23. Zwart S, Rovers MM, de Melker RA, Hoes AW. Penicillin for acute sore throat in children: randomised, double blind trial. BMJ. Dec 6 2003;327(7427):1324. [Medline].

 
Previous
Next
 
The exudative pharyngitis typical of scarlet fever. Although the tongue is somewhat out of focus, the whitish coating observed early in scarlet fever is visible.
Desquamation of the palms is a frequently observed self-limited manifestation of scarlet fever present in the healing period following resolution of the infection and acute eruption.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.