Mom brought five-year-old Braden to the office for a sick visit. He had a fever that started two days ago and now had a headache, nausea and abdominal pain.

 

What prompted today’s visit was a rash on his trunk. Mom said she had just assumed he had the flu. She had been treating him symptomatically with plenty of fluids and Tylenol. But the abdominal pain was a concern for appendicitis, and now he had this rash.

 

Branden looked like he didn’t feel well. His temperature was 101.8 degrees.

 

His eyes were weepy and the rash was noticeable on his chest and back. Upon examination his eyes were not red, his neck was freely moveable with no stiffness, eliminating concern for meningitis, and mild redness in his throat. His ears were clear, ruling out an ear infection. A marble-sized, freely moveable lymph node was under the left jaw and the lungs were clear. He said that his tummy hurt in the middle of his abdomen but that exam was completely benign and normal. The rash on his chest and lower abdomen extended to his groin as well as over his back. It was red and coarse with a “sandpapery” feel. With direct pressure it blanched momentarily and then returned to its red color. Subjectively he complained of a headache and stomach ache but only mildly of a sore-throat.
 

I told mom I thought he had scarlet fever and wanted to do a rapid strep test taking ten minutes. She paused, looked a bit stunned and said, “…Scarlet fever?? Isn’t that serious? It sounds like an infection of the olden days.”

 

I reassured her that if it was scarlet fever Branden would be just fine after taking antibiotics. Scarlet fever is a more invasive form of “strep throat” caused by group A beta-hemolytic streptococcus. In the pre-antibiotic era it was a more serious and problematic disease. If untreated it could lead to serious complications such as rheumatic fever and rheumatic heart disease, kidney involvement (post strep glomerulonephritis) or reactive arthritis. But now with the ability to diagnose group A strep and the many antibiotics available it is not the dreaded disease that it used to be pre-World War II

 

Scarlet fever occurs more commonly in children between the ages of 5 and 15 years. The classic presentation of scarlet fever is fever, headache, sore throat–not in all cases–and possible abdominal pain.

 

Early in the illness the tongue may have a whitish appearance. But after one-to-two days this may lead to a strawberry tongue whereby it becomes slightly swollen and red with white dots or bumps from enlarged taste buds (papillae). This gives it the appearance of a strawberry.
 

After one-to-two days a rash appears on the neck and spreads down the trunk.

 

It is coarse and red with a sandpapery feel–the classic scarletiniform rash which blanches with pressure. It may be more confluent along the skin fold areas of the forearm or groin, forming lines of tiny petechiae or pin point red/purple dots. This is known as Pastia’s lines which is unique to scarlet fever. It is caused by leaky capillaries as a result of an endo-toxin produced by the strep organism. After another three-to-four days the rash will gradually fade away. In another one-to-two weeks there may be peeling or flaking of skin. If untreated, all the symptoms will go away…but the complications may still occur later on. That is why it is CRITICAL to diagnose and treat group A strep. If antibiotics are started within nine days of the onset of symptoms the likelihood of developing rheumatic fever is near negligible.

 

Branden’s strep test came back positive and he was started on a type of penicillin which is the treatment of choice.

 

Mom was told to continue what she was doing, being sure he took plenty of fluids, She should have him gargle with warm salt water for any sore throat, encourage rest and give him something for fever should it go over 100.5 degrees. He would be contagious to others until he completed a full 24 hours of antibiotics. I stressed the importance of finishing the full ten days of antibiotics even if he felt great after a couple of days. This was to insure adequate treatment and elimination of the strep.