eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Scarlet Fever

Author: Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
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: Dec 19, 2007

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.

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

Up to 10% of the population contracts group A streptococcal pharyngitis. Of this group, up to 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

  • The prodrome is characterized by the following findings:
    • Sore throat
    • 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: Edematous, erythematous, and covered with a yellow, gray, or white exudate
  • Petechiae on the soft palate
  • Tender anterior cervical lymphadenopathy
  • Flushed face with perioral pallor
  • Scarlatiniform rash
    • 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
    • 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
References

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

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

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

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

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

  7. 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].

  8. 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.

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

Further Reading

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

Contributor Information and Disclosures

Author

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: 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 Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

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 Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant 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.

 
 
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