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Pediatrics, Scarlet Fever
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.
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References
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].
Chiesa C, Pacifico L, Nanni F, Orefici G. Recurrent attacks of scarlet fever. Arch Pediatr Adolesc Med. Jun 1994;148(6):656-60. [Medline].
Davis H, Karasic R. Pediatric infectious disease. In: Atlas of Pediatric Physical Diagnosis. 3rd ed. 1997:355-7.
Fisher RG, Boyce TG. Rash syndromes. In: Moffet's Pediatric Infectious Diseases: A Problem-Oriented Approach. Lippincott Williams & Wilkins; 2005:374-6.
Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].
Gerber MA. Group A streptococcus. In: Nelson Textbook of Pediatrics. Philadelphia, Pa: WB Saunders Co; 2004:870-4.
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].
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.
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
