January 11, 2010

Scarlet Fever Successfully Treated with IV C-Penicillin.

By: By: Muhamad Na’im B. Ab Razak

4th Year Medical Student, Universiti Sains Malaysia

12 years old Malay boy who is the last out of five siblings with no known medical illnesses was presented with history of prolong high grade fever for two weeks duration associated with chills and rigors, loss of appetite and decrease oral intake. The fever temporarily relieved by tab. Paracetamol. Patient notices rash that starts in abdomen and then become generalized. The rash is itchy, reddish, and non-vesicular. Patient also develops cough and running nose. There is no shortness of breath, pleuritic chest pain and no signs and symptoms of urinary tract infection. On examination, there is mild coated tongue associated with enlarged tonsils and injected throat. Others systems are unremarkable. Throat culture is positive for group A Streptococcus. A diagnosis of Scarlet fever was made and he was treated with IV C penicillin 1 mega unit, QID and fluid therapy. Few days later, the fever subsides and the skin starts to desquamate with sand-paper like feel. His cousin recently suffers from meningitis and his brother has history of similar presentation.


Scarlet fever is an infection caused by toxin-producing group Aβ hemolytic streptococci (GABHS) found in secretions and discharge from the nose, ears, throat, and skin. Scarlet fever may follow streptococcal wound infections or burns, as well as upper respiratory tract infections, but food-borne outbreaks have been reported [Edward J Zabawski Jr]

The syndrome is characterized by exudative pharyngitis, fever, and scarlatiniform rash [Pamela L Dyne]

Characteristic clinical features of scarlet fever include: an initial white covering of the tongue, followed by enlargement of the papillae, giving a distinctive ‘strawberry tongue’ appearance. Patients with severe infections often have nausea and vomiting. The incubation period is short, usually 1–3 days. Rarely, typical rash of scarlet fever is reported with GAS infection from another focus than pharyngitis, such as skin infection [P. del Giudice and O. Chosidow]

Desquamation of the palms is a frequently observed self-limited manifestation of scarlet fever present in the healing period following resolution of the infection and acute eruption. (7-10 days after resolution of the rash and may continue up to 6 weeks) [Jerry Balentine]. The peel off skin may give rise to 'sand-paper' like feel.

Differential diagnosis may include Fifth disease, Rubella, Epstein Barr virus, Enterovirus, Hepatitis B virus, HIV, Streptobacillus moniliformis infection, toxic shock syndrome, secondary syphilis toxic shock syndrome, secondary syphilis, Kawasaki disease, acute lupus erythematosus, morbilliform drug eruption, and juvenile rheumatoid arthritis.

Throat culture or rapid streptococcal test is beneficent in diagnosing the disease. Anti-deoxyribonuclease B and antistreptolysin-O titers also beneficent.

Nowadays, Scarlet fever is no longer associated with the deadly epidemics compared to before. Epidemic due to Scarlet fever has been reported since the year 1848 to 1927 and death occurs particularly due to the under development of antibiotic. Clarence L. Scamman et al has reported Scarlet fever out break occurs due to infected lobster meat in a lobster salad. S.R. Duncan et al has observed two types of epidemic which occurs in 1848 to 1880 due to system being driven by an oscillation in the transmission coefficient (δβ) at its resonant frequency, probably associated with dry conditions in winter and in 1880 to 1900 which linked to poor nutritional standards.

The roles of treatment in scarlet fever are to prevent rheumatic fever, reduce the spread of infection, prevent suppurative complication and shorten the course of disease. [Jerry Balentine]

Traditionally, the treatment of scarlet fever consists of bed rest, fluid therapy, tepid sponging and symptomatic treatment of scarlet fever manifestation. Nowadays, the use of antibiotic plays a great role and penicillin remains as the best choice in treating scarlet fever. Tab. Erythromycin 25-50 mg/kg/day, qid X 10 days may be used in the case of resistant or allergic to penicillin.

If a nephritogenic strain of group Aβ hemolytic streptococci causes infection, the individual has a 10-15% chance of developing glomerulonephritis. A lethal form of streptococcal infection is capable of producing the toxic streptococcal syndrome. [Jerry Balentine]

Risk of acute rheumatic fever following an untreated streptococcal infection has been estimated at 3% in epidemic situations and approximately 0.3% in endemic scenarios. [Jerry Balentine]

Even though rare, hepatitis in association with Scarlet fever has been reported in literature. Until now, the association between scarlet fever and hepatitis has not been established, but two theories have been proposed which are direct toxic tissue injury and immunological mechanism. The first case was reviewed by Mac Mohan and Mallory in 1931. Others include case reported by Kocak et al (1976), M. Girisch & U. Heininger (2000) and Ayla Giiven (2002). The course is often benign and resolve within week. Signs of hepatitis include elevated liver enzymes, negative antibody tests against hepatitis viruses and liver biopsy which shows polymorphonuclear granulocytes infiltrating portal area and necrotic hepatocytes.

Other complication of Scarlet fever includes suppurative complication; cervical adenitis, otitis media or mastoiditis, ethmoiditis, sinusitis, peritonsillar abcess, pneumonia, septicemia, meningitis, osteomyelitis and septic arthritis. [Pamela L Dyne]

The prognosis of scarlet fever is excellent. However, it may re-occur.

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1. Ayla Giiven, "Hepatitis and Hematuria in Scarlet Fever", Indian Journal of Pediatrics, Volume 69: November: 2002.

2. Clarence L. Scamman, Herbert L. Lombard, Edith A. Beckler Et Al, "Scarlet Fever Outbreak Due To Infected Food" American Journal of Public Health, Volume XVII, No 4, April, 1927.

3. Edward J Zabawski Jr, "Scarlet Fever", eMedicine, April 2009


4. Jerry Balentine, "Scarlet Fever", eMedicine, May 2009


5. M. Girisch & U. Heininger, "Scarlet Fever Associated with Hepatitis – A Report of Two Cases", Infection 28, No. 4, URBAN & VOGEL (2000)

6. Pamela L Dyne, "Pediatrics, Scarlet Fever", eMedicine, August 2009


7. Pascal del Giudice & Olivier Chosidow, "Skin Manifestations of Systemic Bacterial Infections", J. Revuz et al. (eds.), Life-Threatening Dermatoses and Emergencies in Dermatology, Springer-Verlag Berlin Heidelberg 2009.

8. S.R. Duncan, Susan Scott & C.J. Duncan, "Modelling the dynamics of scarlet fever epidemics in the 19th century", European Journal of Epidemiology 16: 619-626, Kluwer Academic Publishers, 2000.

9. S. Sen & K.C. Chaudhuri, "Scarlet Fever", Indian Journal of Pediatrics, 1936.

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