eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Scarlet Fever

Author: Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Coauthor(s): Peter Bloomfield, MD, MPH, Resident Physician, UCLA Medical Center/Olive View-UCLA Medical Center Emergency Medicine Residency Program
Contributor Information and Disclosures

Updated: Aug 12, 2009

Introduction

Background

Scarlet fever is a syndrome characterized by exudative pharyngitis, fever, and scarlatiniform rash. It is caused by an infection with a pyogenic exotoxin-producing group A beta-hemolytic streptococci.

The exudative pharyngitis typical of scarlet feve...

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.

[ CLOSE WINDOW ]
The exudative pharyngitis typical of scarlet feve...

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 observe...

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.

[ CLOSE WINDOW ]
Desquamation of the palms is a frequently observe...

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.

Pathophysiology

Streptococci are gram-positive cocci that grow in chains. They are classified by their ability to produce a zone of hemolysis on blood agar and by differences in carbohydrate cell wall components (A-H and K-T).

Streptococci may be alpha-hemolytic (partial hemolysis), beta-hemolytic (complete hemolysis), or gamma-hemolytic (no hemolysis). Most streptococci excrete hemolyzing enzymes and toxins. Erythrogenic toxins cause the rash of scarlet fever. The erythema-producing toxin was discovered by Dick and Dick in 1924.

Group A streptococci are normal inhabitants of the nasopharynx. Group A streptococci can cause pharyngitis, skin infections (including erysipelas pyoderma and cellulitis), pneumonia, bacteremia, and lymphadenitis. Scarlet fever is usually associated with pharyngitis; however, in rare cases, it follows streptococcal infections at other sites.

Infections occur year-round, but the incidence of pharyngeal disease is highest in school-aged children (5-15 y) during winter and spring and in a setting of crowding and close contact. Person-to-person spread by means of respiratory droplets is the most common mode of transmission. It can rarely be spread through contaminated food, as seen in a recent outbreak in China.1

The incubation period for scarlet fever ranges from 12 hours to 7 days. Patients are contagious during the acute illness and during the subclinical phase.

Frequency

United States

As many as 10% of the population contracts group A streptococcal pharyngitis. Of this group, as many as 10% then develop scarlet fever.

Mortality/Morbidity

In the preantibiotic era, infections due to group A beta-hemolytic streptococci were major causes of mortality and morbidity. Now with antibiotics, enhanced immune status of the population and improved socioeconomic conditions, the incidence and rate of complications of these infections has decreased.

Sex

No predilection is observed.

Age

Scarlet fever predominantly occurs in children aged 5-15 years.

Clinical

History

  • Scarlet fever is characterized by the following findings:
    • Sore throat2
    • Headache
    • Vomiting
    • Abdominal pain
    • Fever
  • The rash appears 1-2 days after onset of illness, first on the neck and then extending to the trunk and extremities.

Physical

  • The patient usually appears moderately ill.
  • Fever may be present.
  • The patient may have tachycardia.
  • Tonsils are edematous, erythematous, and covered with a yellow, gray, or white exudate.
  • Petechiae is noted on the soft palate.
  • Tender anterior cervical lymphadenopathy may be present.
  • Flushed face with perioral pallor is observed.
  • Scarlatiniform rash is noted.
    • Exanthem texture is usually of coarse sandpaper, and the erythema blanches with pressure.
    • The skin can be pruritic but usually is not painful.
    • A few days following generalization of the rash, it becomes more intense along skin folds and produces lines of confluent petechiae known as the Pastia sign. These lines are caused by increased capillary fragility.
    • The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later and can last up to a month.
  • Appearance of the tongue consists of the following:
    • During the first 2 days of the disease, the tongue has a white coat through which the red and edematous papillae project. This is referred to as a white strawberry tongue.
    • After 2 days, the tongue also desquamates, resulting in a red tongue with prominent papillae called the red strawberry tongue.

Causes

  • Scarlet fever results from an erythrogenic toxin produced by group A streptococci.

More on Pediatrics, Scarlet Fever

Overview: Pediatrics, Scarlet Fever
Differential Diagnoses & Workup: Pediatrics, Scarlet Fever
Treatment & Medication: Pediatrics, Scarlet Fever
Follow-up: Pediatrics, Scarlet Fever
Multimedia: Pediatrics, Scarlet Fever
References
[ CLOSE WINDOW ]

References

  1. Yang SG, Dong HJ, Li FR, Xie SY, Cao HC, Xia SC. Report and analysis of a scarlet fever outbreak among adults through food-borne transmission in China. J Infect. Nov 2007;55(5):419-24. [Medline].

  2. [Guideline] Finnish Medical Society Duodecim. Sore throat and tonsillitis. EBM Guidelines. Evidence-Based Medicine. Feb 2 2007;Helsinki, Finland: Wiley Interscience. John Wiley & Sons:[Full Text].

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

  4. Chiesa C, Pacifico L, Nanni F, Orefici G. Recurrent attacks of scarlet fever. Arch Pediatr Adolesc Med. Jun 1994;148(6):656-60. [Medline].

  5. Davis H, Karasic R. Pediatric infectious disease. In: Atlas of Pediatric Physical Diagnosis. 3rd ed. 1997:355-7.

  6. Fisher RG, Boyce TG. Rash syndromes. In: Moffet's Pediatric Infectious Diseases: A Problem-Oriented Approach. Lippincott Williams & Wilkins; 2005:374-6.

  7. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].

  8. Gerber MA. Group A streptococcus. In: Nelson Textbook of Pediatrics. Philadelphia, Pa: WB Saunders Co; 2004:870-4.

  9. Hamour A, Bonnington A, Wilkins EG. Severe community acquired pneumonia associated with a desquamating rash due to group A beta-haemolytic streptococcus. J Infect. Jul 1994;29(1):77-81. [Medline].

  10. Kaplan EL, Gerber MA. Group A, group C and group G beta-hemolytic streptococcal infections. In: Textbook of Pediatric Infectious Diseases. Philadelphia: PA: Saunders; 2004:1142-56.

  11. Kleiegman RM, Feigin RD. Streptococcal infections. In: Nelson Textbook of Pediatrics. 14th ed. Philadelphia, Pa: WB Saunders Co; 1992:698-703.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

scarlatina, scarlatinella, scarlatiniform rash, group A streptococcal pharyngitis, strep throat, group A streptococci, group A beta-hemolytic streptococci, group A streptococcal toxin, strep throat, erythrogenic toxins, pharyngitis, petechiae on soft palate, flushed face with perioral pallor, anterior cervical lymphadenopathy, erythematous exanthem, Pastia sign, white strawberry tongue, red strawberry tongue, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Peter Bloomfield, MD, MPH, Resident Physician, UCLA Medical Center/Olive View-UCLA Medical Center Emergency Medicine Residency Program
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
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

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
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.