CASE #2

A 7 years old female came in due to fever of 10 days accompanied by sore throat, anorexia and
vomiting. Eight days prior to admission, still febrile, the patient was noted to be flushed with
multiple pinpoint pruritic erythematous maculopapular rashes initially seen on the neck and
trunk later spreading to the abdomen and extremities, sparing the face. Rashes were noted to
blanch on pressure. She also developed non productive cough. Six days prior to admission, the
rashes became brownish in color and started to desquamate after 2 days. A day PTA, she
developed abdominal pain with loose stools for which she was eventually confined. PE showed a
coherent ambulatory patient with warm dry skin with multiple hyperpigmented maculopapular
lesions on the neck, trunk and abdomen with areas of desquamation on the hypogastric area,
upper and lower extremities Buccal mucosa was moist with tonsillopharyngeal congestion and
exudates.
SALIENT FEATURES:
7 years old
Fever of 10 days
Sore throat
Anorexia, vomiting
Flushed
Multiple pinpoint pruritic erythematous maculopapular rashes from the neck and trunk and
spreading to abdomen and extremities, sparing the face
Rashes blanch on pressure
Nonproductive cough
6 days PTA rashes desquamate
A day PTA, abdominal pain with loose bowel stools
On PE:
Warm dry skin, multiple hyperpigmented maculopapular lesions in the neck, trunk and abdomen
With areas of desquamation on the hypogastric area, upper and lower extremities.
Tonsillopharyngeal congestion with exudates.
Rubeola (Measles)
Rule in
Rule out
Maculopapula Rashes
r rashes
sparing
the
face
Fever
Sore throat
Desquamatio
n
cough

Rubella
Rule in
Maculopapula
r rashes

Rule out
Rashes
sparing
the
face
Sore throat

Dengue Fever
Rule in
Maculopapula
r
pinpoint
rashes
Anorexia

Anorexia

Anorexia

Vomiting

Vomiting

Vomiting

Abdominal
pain

No enanthem

No enanthem

Desquamatio
n

Rule out
Fever of
days

10

Desquamatio
n of rashes

** in adults, a prodrome of fever, sore throat and rhinitis, may be present in rubella, in children, it
may be absent.
Impression:
Scarlet Fever

Scarlet fever is caused by an infection with group A streptococcus bacteria (usually strep
throat). The bacteria make a toxin (poison) that can cause the scarlet-colored rash that
gives this illness its name.
Not all streptococci bacteria make this toxin and not all kids are sensitive to it. Two kids
in the same family may both have strep infections, but one child (who is sensitive to the
toxin) may develop the rash of scarlet fever while the other doesn't.
Usually, if a child has this scarlet rash and other symptoms of strep throat, it can be
treated with antibiotics. So if your child has these symptoms, it's important to call your
doctor.

Symptoms
The rash is the most striking sign of scarlet fever. It usually begins looking like a bad
sunburn with tiny bumps and it may itch. The rash usually appears first on the neck and
face, often leaving a clear unaffected area around the mouth. It spreads to the chest
and back, then to the rest of the body. In body creases, especially around the
underarms and elbows, the rash forms classic red streaks. Areas of rash usually turn
white when you press on them. By the sixth day, the rash usually fades, but the affected
skin may begin to peel.

Aside from the rash, there are usually other symptoms that help to confirm a diagnosis
of scarlet fever, including a reddened sore throat, a fever above 101F (38.3C), and
swollen glands in the neck. The tonsils and back of the throat may be covered with a
whitish coating, or appear red, swollen, and dotted with whitish or yellowish specks of
pus. Early in the infection, the tongue may have a whitish or yellowish coating. A child
with scarlet fever also may have chills, body aches, nausea, vomiting, and loss of
appetite.
When scarlet fever happens because of a throat infection, the fever usually stops within
3 to 5 days, and the sore throat passes soon afterward. The scarlet fever rash usually

fades on the sixth day after sore throat symptoms began, but skin that was covered by
rash may begin to peel. This peeling may last 10 days.
The infection itself is usually cured with a 10-day course of antibiotics, but it may take a
few weeks for tonsils and swollen glands to return to normal.
In rare cases, scarlet fever may develop from a streptococcal skin infection
like impetigo. In these cases, the child may not get a sore throat.

Approach Considerations
The diagnosis is mostly based on the clinical presentation. However, leukocytosis
with left shift presentation and possibly eosinophilia a few weeks after
convalescence on a standard blood test and urine tests are part of a complete
medical workup. The following studies are indicated in scarlet fever:
Throat or nasal culture or rapid streptococcal test Antideoxyribonuclease B, antistreptolysinO titers (antibodies to
streptococcal extracellular products), antihyaluronidase, and antifibrinolysin
can be valuable in confirmation of the diagnosis In most cases, no imaging studies are indicated.
Blood and Urine Studies
The complete blood cell (CBC) count commonly reveals a leukocytosis. The white
blood cell (WBC) count in scarlet fever may increase to 12,00016,000/L, with a
differential of up to 95% polymorphonuclear leukocytes. During the second week,
eosinophilia, as high as 20%, can develop.
Urinalysis and liver function tests may reveal changes associated with complications
of scarlet fever. Said tests are part of a complete medical workup. Hemolytic
anemia can occur, and mild albuminuria and hematuria may be present early in the disease.
Patients whose bacterial source may suggest another process (eg, a patient with a
suppurative leg wound who may have osteomyelitis) should be evaluated accordingly.
Throat Culture
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 are found on throat culture during acute infection.[15]
Throat cultures are approximately 90% sensitive for the presence of group A betahemolytic strep
tococci (GABHS) in the pharynx. However, because a 1015%
carriage rate exists among healthy individuals, the presence of GABHS 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 enzymelinked immunosorbent
assay (ELISA). Several studies of RAT kits report results of 95% specificity but only 7090% sensitivity. Operator technique can also significantly influence the results of the test.[16]
Antideoxyribonuclease B and Antistreptolysin O Titers
Streptococcal antibody tests (eg, antideoxyribonuclease B [ADB] and
antistreptolysin O [ASO] titers) are used to confirm previous group A streptococcal
infection. The most commonly available streptococcal antibody test is the ASO test.
An increase in ASO titers can sometimes be observed but is a late finding and
usually of value only in retrospect.
Streptococcal antibody tests can provide confirmatory evidence of recent infection
but have no value in acute infection and currently are not indicated in this setting.
They may be of value in patients with suspected acute renal failure or acute glomerulonephritis.
Histologic Findings
The microscopic findings of the eruption of scarlet fever are nonspecific and have an
appearance similar to that of other exanthematous eruptions. A sparse neutrophilic
perivascular infiltrate is present, with a slight amount of spongiosis in the epidermis.
Slight parakeratosis may be present, which probably correlates with the
sandpaperlike texture of the skin. The spongiosis and parakeratosis are more
noticeable during the desquamative stage. Engorged capillaries and lymphatic

dilatation perifollicularly, as well as the presence of dermal hemorrhage and edema,

are easily detected.
Approach Considerations
The goals in the treatment of scarlet fever are (1) to prevent acute rheumatic fever,
(2) to reduce the spread of infection, (3) to prevent poststreptococcal
glomerulonephritis and suppurative sequelae (eg, adenitis, mastoiditis, ethmoiditis,
abscesses, cellulitis), and (4) to shorten the course of illness.
Antibiotic therapy is the treatment of choice for scarlet fever. Whether antibiotics
prevent poststreptococcal glomerulonephritis is still debated in the literature.
Medical Care
Penicillin (or amoxicillin) remains the drug of choice (documented cases of penicillinresistant grou
p A streptococcal infections still do not exist). A firstgeneration
cephalosporin may be an effective alternative, as long as the patient does not have
any documented anaphylactic reactions to penicillin. If this is the case, clindamycin
or erythromycin may be considered as an alternative.[17, 18] However, some strains
of group A streptococci may not be susceptible to macrolides. Hence, in this
situation, it is crucial to contact the microbiology laboratory with regard to the
sensitivity of the organism to macrolide antibiotics. A 10 to 14day course of
treatment is usually recommended, and clinical improvement should be noted after 2448 hours of antibiotic initiation.
Cultures should be obtained where organisms other than streptococcal bacteria are
suspected. The desquamating rash that follows is selflimited, with only emollients
necessary for care. If odynophagia accompanying streptococcal pharyngitis is especially severe,
hospitalization may be warranted for intravenous hydration and antibiotics.
Prevention
At this time, a vaccine for group A streptococci does not exist.[19] To minimize
contagion, children with scarlet fever should not return to school or daycare until
they have completed 24 hours of antibiotic therapy and are clinically improving.
Hand hygiene and proper maintenance of environmental hygiene should be highly reinforced.
Consultations
If the diagnosis is unclear, consultation with a dermatologist is recommended. For
serious complications, an infectious disease specialist should be consulted. Referral
to an otolaryngologist for tonsillectomy may be recommended for patients with
recurrent pharyngitis.
LongTerm Monitoring
Followup evaluation is recommended to ensure resolution of the primary infection.
Some patients report pruritus associated with the desquamating rash. Oral
antihistamines and emollients usually are sufficient to control the pruritus.
Medication Summary
Treatment is aimed at providing adequate antistreptococcal antibiotic levels for at least 10 days.
Treat patients who have scarlet fever with a standard 10day course of oral penicillin
VK or erythromycin. Patients can also be treated with a single intramuscular
injection of penicillin G benzathine. These regimens may prevent acute renal failure
if antibiotics are initiated within 1 week of the onset of acute pharyngitis. Firstgeneration cephalo
sporins may also be used. Erythromycin should be considered in
patients allergic to penicillin. Tetracyclines and sulfonamides should not be used.
Antibiotics Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely
pathogens in the context of the clinical setting.
View full drug information Penicillin G benzathine (Bicillin LA)
Penicillin G interferes with synthesis of cell wall mucopeptides during active
multiplication, which results in bactericidal activity. View full drug information Penicillin VK
Penicillin VK is the drug of choice. It inhibits biosynthesis of cell wall mucopeptides
and is effective during active multiplication. Inadequate concentrations may produce
only bacteriostatic effects.
View full drug information Amoxicillin (Moxatag)
Amoxicillin is an alternative drug of choice. It interferes with synthesis of cell wall
mucopeptides during active multiplication, resulting in bactericidal activity against
susceptible bacteria.
View full drug information Erythromycin (E.E.S., EMycin, EryTab)
Erythromycin is the drug of choice in penicillinallergic patients. It inhibits bacterial
growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNAdependent protein synthesis to arrest. It is used for treatment of infections
caused by susceptible strains, including streptococci.
In children, age, weight, and severity of infection determine proper dosage. When twicedaily dosing is desired, half of the total daily dose may be taken every 12
hours. For more severe infections, double the dose.
View full drug information Cephalexin (Keflex)
Cephalexin is an alternative drug of choice. It is a firstgeneration cephalosporin that
arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal
activity against rapidly growing organisms. Its primary activity is against skin flora it
is used for skin infections.