Scarlet fever

Sydenham 1676.

Scarlet fever, Scarlatina, Streptococcal sore throat with rash, Canker rash. 

Notifiable, acute infection with β-haemolytic streptococci of group A leading to angina, general symptoms and macular exanthema.

The age peak is between the ages of 3-15.

• The cause of the disease is β-hemolyzing streptococci of group A (a total of over 60 serotypes are counted). Usually scarlet fever occurs in connection with angina. However, other diseases with Group A streptococci can also be the cause. Transmission is by droplet infection, contact or food and is favoured by cold weather. The entry ports include nasopharynx and wounds. The streptococci form erythrotoxin (A, B, C), which has superantigenic action and stimulates proinflammatory cytokines.

• Incubation period: 2-5 days.

• Reduced general condition with febrile temperature, headache, sore throat, vomiting and pharyngotonsillitis with locoregional lymphadenopathy.
• An exanthem with needle-sized, follicularly bound papules and small blisters (Miliaria scarlatinosa) can occur, possibly with a time delay. In some cases, however, cutaneous manifestation does not occur. Usually initial inguinal, at the thigh triangle or the arm bends. In most cases there is generalization (including the palms of the hands and feet), usually with a recess in the face. Punctiform erythematous spots can be seen on the back of the hand and foot. At strong eruption pressure the cheeks are reddened. Facies scarlatinosa is called the characteristic perioral zone without skin findings.
• The "raspberry tongue" is typical. A macular enanthem occurs in the Palatinum molle area.
• In some cases a subicterus can be observed. The capillaries show increased tearability during the disease (see Rumpel-Leee-Test).

• Clinic.
• Blood count (leukocytosis, in the course of eosinophilia).
• ESR, CRP increased.
• Bacterial swab of the throat for pathogen detection.
• ASL titre (increase after approx. 1-2 weeks after infection).
• Typical is also a white dermographism occurring after 20 seconds.
• Previously, the thick test was performed by injecting 0.1 ml thick toxin (erythrogenic streptococcal toxin) i.c.. If after up to 20 hours no reddening of the skin > 1 cm appears, the existence of antibodies against erythrogenic toxins must be assumed. In this case, the patient is immune to scarlet fever.
• The eradication phenomenon occurs up to 20 hours after intradermal injection of 0.2 ml scarlet convalescent serum or 0.3 ml antistreptococcal serum as pallor. If a recess in the exanthema is visible, scarlet fever can be assumed. If the test is negative, you have to think of other triggers of the exanthema.
• In the Rumpel-Leade test, a blood pressure cuff is pumped up to 50 mmHg and left for at least 5 minutes. If there are more than 5 petechiae within a radius of 5 cm of the cuff, this should be considered positive. In scarlet fever patients, this test is often positive.

• Hyperpyrexia
• Disturbed consciousness
• Spasms
• Purpura
• Septicemia
• Otitis media
• Sinusitis
• Myocarditis
• Acute glomerulonephritis
• Polyarthritis
• Pneumonia
• Pericarditis
• Meningitis
• Hepatitis
• Glomerulonephritis
• Rheumatic fever
• PANDAS syndrome
• Nekrotizing Fascitis

• Letality: < 0.5%.
• After suffering from scarlet fever, immunity lasts a lifetime. However, there are 3 different variants of erythrotoxin, so that immunity after scarlet disease exists only against one variant.

• Kindergarten and school ban! Risk of infection (untreated) 1-3 Where in Kindergarten.
• Observe the obligation to register!
• At a body temperature of > 38°C decrease of blood cultures.
• Early therapy is important!
• Penicillin V p.o. 3x daily 0.4-1.2 million IU (infants: 0.2-0.6 million IU/day) for about 10 days.
• Alternative: PenicillinG intravenously 4 million IU 6x daily.
• Alternatively: Erythromycin p.o. 500 mg 3x per day, maximum dose: 4 g/d (adult), 40-100 mg/kg bw/day (5-12 years).
• Alternative: Clindamycin p.o. 600 mg 3x per day.
• Alternatively: Cefuroxim p.o. 250-500 mg 2x per day (> 12 years), 125 mg 2x per day (5-12 years and ≥ 15 kg) (CAVE: cross allergy).
• Treatment of other children living in the household is recommended!

If group A streptococci persist in the throat after antibiotic treatment (in about 10-15%), no new therapy is indicated. 

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2. Silva-Costa, C., et al., Scarlet fever is caused by a limited number of Streptococcus pyogenes lineages and is associated with the exotoxin genes ssa, speA and speC. Pediatr Infect Dis J, 2014. 33(3): p. 306-10.
3. Wang, L.Y. and T.H. Young, Hepatitis, gallbladder hydrops, splenomegaly, and ascites in a child with scarlet fever. Pediatr Emerg Care, 2012. 28(11): p. 1215-7.
4. Paul, S.P. and P.A. Heaton, At a glance: scarlet fever in children. J Fam Health Care, 2014. 24(3): p. 25-7.
5. Wessels, M.R., Pharyngitis and Scarlet Fever, in Streptococcus pyogenes: Basic Biology to Clinical Manifestations, J.J. Ferretti, D.L. Stevens, and V.A. Fischetti, Editors. 2016: Oklahoma City (OK).
6. [Scarlet fever and other infections from Streptococcus pyogenes]. Med Monatsschr Pharm, 2001. 24(3): p. 83-6.