Scarlet Fever


Article Author:
Salvatore Pardo


Article Editor:
Thomas Perera


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
2/28/2019 10:47:21 PM

Introduction

Scarlet fever is a rash most commonly associated with bacterial pharyngitis in school-age and adolescent children. It is a blanching, papular rash that is classically described as a “sandpaper” rash. The causative bacteria is Streptococcus pyogenes, which generates an endotoxin mainly responsible for the skin manifestation of the infection. This is further classified as group A and referred to as Group A Strep (GAS). Alone, the rash is not dangerous but is a marker for GAS infection which has suppurative and non-suppurative complications. Therefore, treatment of the acute infection is warranted to prevent these complications. The first-line treatment of choice is penicillin. Those allergic to penicillin can be treated with a first-generation cephalosporin. The spread of infection is promoted by mucosal transfer of bacteria to others via an environment of close proximity found in classrooms and similar workplace settings.[1][2][3]

Etiology

The causative agent in scarlet fever is GAS, a gram-positive coccus that grows in chains. Scarlet fever is caused by the release of endotoxins. The bacteria also is classified as a beta hemolytic strep which can cause complete red cell destruction (GABHS). The bacteria is the causative agent of strep throat, impetigo, erysipelas, cellulitis, and necrotizing fasciitis.[4]

Epidemiology

Scarlet fever is a disease of childhood due to ease of transmission in the classrooms and nurseries. It is most commonly associated with bacterial pharyngitis caused by GAS or strep throat. Wounds and burns infected with GAS also can cause scarlet fever. It has been reported that strep throat is the responsible for 15% to 30% of all pharyngitis in children aged 5 to 15 years old. In adults, the rate is 5% to 15%.  Non-school-aged children in contact with school-aged children in the same household are also at risk. There is no gender preference for scarlet fever.  [3][5][6]

Multiple studies have reported the emergence of scarlet fever coinciding with the initiation of the school year and the colder temperatures as winter approaches. A decrease in the rate of infection can be attributed to times when school is not in session during the spring and warming temperatures. The difference in rates between children and adults is likely due to the presence or absence of immunity. The prevalence is higher in undeveloped countries. This is probably due to the more likely presence of crowded living quarters. An article on the epidemiology of scarlet fever in Hong Kong reported an increase in the incidence of disease from 3.3/10,000 to 18.1/10,000. Similar increases have been reported in Great Britain. The increase has not been explained, but resistant strains of GAS are suspected.

Pathophysiology

Scarlet fever is a rash resulting from an infection caused by GAS. The exotoxin produced by the bacteria causes the classic “sandpaper” rash.  The toxins cause a local inflammatory response on the skin and are referred to as erythrogenic toxins. 

Histopathology

There are no specific histological changes in scarlet fever. One will observe neutrophilic infiltrate with spongiosis and parakeratosis in the epidermis. 

History and Physical

Typically, scarlet fever is associated with an acute pharyngitis. As a result, fever, sore throat, pain with swallowing, and cervical adenopathy is present. If there is no pharyngitis, the source of infection can be a wound or burn which is infected with GAS. The two vectors of infection can both cause scarlet fever and are not distinguishable from one another. The rash itself is a blanching, papular rash. It is distinguished from the macular rash found an allergic reaction by its insidious emergence and lack of confluence of the lesions. This lack of confluence is the primary reason it feels like sandpaper. Also of note, there are no vesicles or pustules present. Vesicles are more associated with the “dew on a rose petal” appearance of chicken pox in its initial stages. Pustules are more indicative of a local infection such as impetigo or erysipelas. The rash develops within 2 to 3 days after infection but can be delayed up to 7 days. The trunk, underarms, and groin are affected first, and then it spreads to the extremities. Usually, the palms and soles are spared. The circumoral area is also spared, making it pallor-like. The “strawberry tongue” begins with a white coating of the tongue with hyperplastic papillae. As the white coating resolves, the papules remain, giving the appearance of a strawberry. Pastia lines are found in the folds of the skin such as the neck, antecubital fossa, and groin. This appears as a linear accumulation of papules around pressure points. After the initial rash begins to resolve, a period of desquamation can occur and last up to two weeks in some cases. 

Evaluation

When evaluating a person suspected of having scarlet fever, there are several things to consider. After carefully taking a history and physical, the next steps of the evaluation can be considered. In cases associated with pharyngitis, lack of a cough, exudates, cervical nodes, temperature, and age (less than 15 years) help determine the likelihood of strep throat. This is known as the CENTOR criterion.[7][8][9]

Testing available to the clinician includes throat culture and the rapid strep test. Both test for the presence of GAS. The throat culture takes longer (days) and is more specific, and the rapid test is immediate (minutes) and less specific. The use of the rapid strep test with older persons (greater than 45 years) is controversial since they are more likely to be a carrier state and have lower prevalence in that age group. This combination may increase exposure to inappropriate antibiotics and increased resistance.

Therefore, in young patients with a high CENTOR score, rapid strep is recommended to confirm the infection and treatment is initiated. Depending on your practice environment and follow up, your decision to treat may be influenced. 

Treatment / Management

Since scarlet fever is due to an infection caused by GAS, it is treated with antibiotics. Penicillin or amoxicillin is the first-line treatment. If the affected person has an allergy to penicillin, a first-generation cephalosporin can be used. The use of antibiotics has reduced the morbidity and mortality of scarlet fever when compared to the early 20th century when the mortality was approximately 30%. [10][11][12]

GAS has its reservoir in the nasal mucosa, adenoids, tonsils. Asymptomatic individuals who test positive for GAS are generally referred to as carriers. Current practice deters treatment of carriers with antibiotics.

Differential Diagnosis

The differential diagnosis of a fever and a rash are broad. In the clinical scenario of a sandpaper rash in the presence of a sore throat and fever, GAS infection should be seriously considered. Use of the CENTOR criteria and testing can be utilized. Pustules are more indicative of a local infection such as impetigo or erysipelas. Some viral illnesses which should be considered in the affected population are measles (rubeola), chicken pox (herpes zoster), and hand-foot-and-mouth disease (Coxsackie), which all have specific presentations that distinguish them from scarlet fever. Good immunization, travel, and medical history should be considered when a patient presents with fever and a rash.

Prognosis

When compared to the prognosis of scarlet fever in the early 20 century, the prognosis of scarlet fever is excellent. This mainly due to the introduction of antibiotics and hygiene. After the diagnosis is made and treatment is initiated, the patient can return to normal activity 24 hours after the fever has resolved. Left untreated, the prognosis decreases and the likelihood of complications stemming from group A strep infection increases. Suppurative and non-suppurative complications abscess near the local area of infection to kidney injury.

Complications

Historically, scarlet fever was a disease with a high complication rate and even death among children. With the development of antibiotics and treatment regimens, scarlet fever is now considered a relatively mild disease. However, complications from delayed or untreated GAS are significant. The complications fall into two categories, suppurative and non-suppurative. Typically, suppurative complications result from a worsening, an extension, or a spread of the original area of infection. As an example, a bacterial pharyngitis can spread to the ear, causing otitis media; the sinuses, causing a sinusitis; and then to the meninges, causing bacterial meningitis. Non-suppurative complications generally are mediated through an immune response after the original infection resolves. Rheumatic fever, a disease affecting the heart valves, is a complication of GAS infection that results in long-term morbidity.

Although not directly caused by scarlet fever, below is a partial list of complications due to GAS infection.

Suppurative

  • Peritonsillar/pharyngeal abscess
  • Otitis media
  • Sinusitis
  • Necrotizing fasciitis
  • Streptococcal bacteremia
  • Meningitis or brain abscess
  • Jugular vein septic thrombophlebitis 

Non-Suppurative

  • Acute rheumatic fever
  • Poststreptococcal reactive arthritis
  • Streptococcal toxic shock syndrome
  • Acute glomerulonephritis
  • Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci

Deterrence and Patient Education

Scarlet fever and most diseases which are transmitted via close contact can be avoided by using good hand hygiene, covering your coughs and sneezes, regular disinfection of shared fomites, and avoiding others when infected. Reminders in public areas in the form of posters and public service announcements in the media are some of the ways to increase these good hygiene practices. The public also should be aware of the risks associated with the overuse of antibiotic administration which may introduce resistant strains of GAS. 

Enhancing Healthcare Team Outcomes

Scarlet fever is best managed by a multidisciplinary team. The key to treatment is patient education. The pharmacist should emphasize to the patient that full recovery occurs when antibiotic compliance is complete. In addition, the nurse should educate the patient on hand and personal hygiene to prevent transmission of the bacteria to others. Patients should be educated about the skin infection and the general exfoliation, and when to seek medical assistance. The skin symptoms are frequently relieved with the use of emollients and oral antihistamines.[13][14] (Level V)

Outcomes

For the majority of patients treated promptly, the outcome is excellent. Recovery is usually complete in 3-6 days but the skin symptoms may take 14-21 days to subside. In a few people, the infection can recur. In the era of antibiotics, mortality from scarlet fever is less than 1%. The morbidity of scarlet fever is most likely due to glomerulonephritis, rheumatic fever, sinusitis, and other infections. Complications, though, are rare.[15][2] (Level V)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Scarlet Fever - Questions

Take a quiz of the questions on this article.

Take Quiz
In which of the following disorders would one expect to see a strawberry tongue?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the first-line treatment for scarlet fever?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the drug of choice to treat scarlet fever in a patient with penicillin allergy?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 7-year-old with a sore throat, fever, vomiting, headache, and a rash is brought into the office. The exam shows grey-white exudates on hyperemic tonsils and the entire pharynx is erythematous. There is a papular, erythematous rash over the groin, axillae, and the cubital fossae and is starting on the trunk. Which of the following is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What causes scarlet fever?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A child presents with a sore throat and fever. A rapid strep is positive and you begin treatment. She returns with an erythematous, finely punctate rash beginning on the upper chest and spreading to the entire body. Red lines are seen in the skin folds of the neck, axillae, elbows, groin, and knees. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Scarlet Fever - References

References

Managing scarlet fever. BMJ (Clinical research ed.). 2018 Aug 30     [PubMed]
Yung CF,Thoon KC, A 12 year outbreak of scarlet fever in Singapore. The Lancet. Infectious diseases. 2018 Sep     [PubMed]
Barnett TC,Bowen AC,Carapetis JR, The fall and rise of Group A Streptococcus diseases. Epidemiology and infection. 2018 Aug 15     [PubMed]
Brockmann SO,Eichner L,Eichner M, Constantly high incidence of scarlet fever in Germany. The Lancet. Infectious diseases. 2018 May     [PubMed]
Zhang Q,Liu W,Ma W,Zhang L,Shi Y,Wu Y,Zhu Y,Zhou M, Impact of meteorological factors on scarlet fever in Jiangsu province, China. Public health. 2018 Aug     [PubMed]
Lee CF,Cowling BJ,Lau EHY, Epidemiology of Reemerging Scarlet Fever, Hong Kong, 2005-2015. Emerging infectious diseases. 2017 Oct     [PubMed]
Managing scarlet fever. Drug and therapeutics bulletin. 2017 Sep     [PubMed]
Chalker V,Jironkin A,Coelho J,Al-Shahib A,Platt S,Kapatai G,Daniel R,Dhami C,Laranjeira M,Chambers T,Guy R,Lamagni T,Harrison T,Chand M,Johnson AP,Underwood A, Genome analysis following a national increase in Scarlet Fever in England 2014. BMC genomics. 2017 Mar 10     [PubMed]
Wessels MR, Pharyngitis and Scarlet Fever null. 2016     [PubMed]
Hübner J,Jansson A, [Scarlet fever]. MMW Fortschritte der Medizin. 2012 Oct 18     [PubMed]
Lamden KH, An outbreak of scarlet fever in a primary school. Archives of disease in childhood. 2011 Apr     [PubMed]
Hedrick J, Acute bacterial skin infections in pediatric medicine: current issues in presentation and treatment. Paediatric drugs. 2003     [PubMed]
Salerno J, Pediatric management problems. What is your assessment? Scarlet fever. Pediatric nursing. 1996 Mar-Apr     [PubMed]
Radikas R,Connolly C, Young patients in a young nation: scarlet fever in early nineteenth century rural New England. Pediatric nursing. 2007 Jan-Feb     [PubMed]
Wang HC,Lau CI,Lin CC,Chang A,Kao CH, Group A Streptococcal Infections Are Associated With Increased Risk of Pediatric Neuropsychiatric Disorders: A Taiwanese Population-Based Cohort Study. The Journal of clinical psychiatry. 2016 Jul     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.