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Scarlet Fever: Differential Diagnoses & Workup

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
Coauthor(s): Daniel P Lombardi, DO, Clinical Assistant Professor, New York College of Osteopathic Medicine; Clinical Preceptor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Interim Program Director, Department of Emergency Medicine, Saint Barnabas Hospital
Contributor Information and Disclosures

Updated: May 7, 2009

Differential Diagnoses

Abortion, Septic
Mononucleosis
Pediatrics, Kawasaki Disease
Roseola
Staphylococcal Scalded Skin Syndrome

Other Problems to Be Considered

Drug-induced syndromes

Workup

Laboratory Studies

  • Throat culture remains the criterion standard for confirmation of group A streptococcal upper respiratory infection.
    • American Heart Association guidelines for prevention and treatment of rheumatic fever state that group A streptococci virtually always is found on throat culture during acute infection.1
    • Throat cultures are approximately 90% sensitive for the presence of group A beta-hemolytic streptococci in the pharynx. However, because a 10-15% carriage rate exists among healthy individuals, the presence of group A beta-hemolytic streptococci is not proof of disease.
    • To maximize sensitivity, proper obtaining of specimens is crucial.
    • Vigorously swab the posterior pharynx, tonsils, and any exudate with a cotton or Dacron swab under strong illumination, avoiding the lips, tongue, and buccal mucosa.
  • Direct antigen detection kits (ie, rapid antigen tests [RATs], strep screens) have been proposed to allow immediate diagnosis and prompt administration of antibiotics.
    • Kits are latex agglutination or a costlier enzyme-linked immunosorbent assay (ELISA).
    • Several studies of RAT kits report results of 95% specificity but only 70-90% sensitivity. Operator technique can also significantly influence the results of the test.2
  • Streptococcal antibody tests are used to confirm previous group A streptococcal infection.
    • The most commonly available streptococcal antibody test is the antistreptolysin O test.
    • Currently, streptococcal antibody tests are not indicated during acute illness.
  • Complete blood count
    • White blood cell (WBC) count in scarlet fever may increase to 12,000-16,000 per mm3, with a differential of up to 95% polymorphonuclear lymphocytes.
    • During the second week, eosinophilia, as high as 20%, can develop.

Imaging Studies

In most cases, no imaging studies are indicated.

More on Scarlet Fever

Overview: Scarlet Fever
Differential Diagnoses & Workup: Scarlet Fever
Treatment & Medication: Scarlet Fever
Follow-up: Scarlet Fever
Multimedia: Scarlet Fever
References
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References

  1. 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].

  2. 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].

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

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

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

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

  7. 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.

  8. 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].

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

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

  16. 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].

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

  19. 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].

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Further Reading

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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; Clinical Preceptor, Albert Einstein College of Medicine of Yeshiva University; Attending Physician and Interim 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.

Medical Editor

Joseph A Salomone, III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine
Joseph A Salomone, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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.

 
 
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