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Scarlet Fever Made Very Simple and Easy
- 1. Bacterial Exanthems Part II: Scarlet Fever:
- 2. Definition and nomenclature: • A disease manifested by pharyngitis, fever and a distinctive scarlatiniform rash caused by toxin‐producing group A β‐haemolytic streptococci, Synonyms and inclusions: • Scarlatina
- 3. Epidemiology: Incidence and prevalence • The disease occurs worldwide. Age • Scarlet fever is mainly a disease of young children who do not have protective antibodies against streptococcal exotoxins. • Most cases between the ages of 5 and 15 years although infections are reported in infancy and adults.
- 4. Epidemiology Contd: Sex • Equal ratio of males and females. Ethnicity • More common in conditions of overcrowding, least affluent populations and areas of poor sanitation. Associated diseases • Rheumatic fever, • Poststreptococcal glomerulonephritis, • Osteomyelitis.
- 5. Pathophysiology: Predisposing factors: • An acute infection caused by strains of Streptococcus pyogenes producing pyrogenic exotoxin (erythrogenic toxin, erythrotoxin), of which there are three types, A, B and C • All three are capable of producing scarlet fever. • Type A is believed to have been responsible for the severe disease seen several decades ago.
- 6. Pathology: • The Erythrogenic toxin is responsible for: – cutaneous vasodilatation, which is associated with oedema and a perivascular cellular infiltrate. – A degenerative myocarditis. • The Bacterial component of the syndrome causes: – septic lesions in many organs, with abscess formation. • The Immunologic component causes: – Glomerulonephritis – Rheumatiic Fever • An attack with a rash confers permanent, specific antitoxic immunity. The toxin produced by other strains is not neutralized, hence second attacks, although rare, can occur.
- 7. Causative organisms: Streptococcus pyogenes. Sources of infection: – Droplet infection is the commonest – Surgical and other wounds may be the source – Spread by fomites or – By milk. A 1930s American poster attempting to curb the spread of such diseases as scarlet fever by regulating milk supply
- 10. Clinical features: • Incubation period: 2–5 days • Abrupt onset with: Fever, anorexia and vomiting. • Cutaneous Findings: – Rash: • A characteristic rash, appears on the second day, first on the upper trunk, is a finely punctate erythema likened to ‘sunburn with goose pimples’ or ‘sandpaper’. • It generalizes within a few hours or over 3 or 4 days. • The lower legs are involved last and least. • After 7–10 days, the rash is succeeded by desquamation, branny in most areas but in large lamellar scales on the palms and soles. – Pastia Lines: • Transverse red streaks in the skin folds due to capillary fragility. – Peri-Oral Pallor: • The face is flushed but rarely shows punctate erythema, and relative pallor around the mouth is characteristic. – Wounds: • If a wound is the source of infection, there may be increased tenderness and some serous discharge.
- 11. Sand paper Rash of scarlet fever in the Fig above and below: Desquamation of soles
- 12. Time Line for Cutaneous Manifestations:
- 13. Clinical Features Contd: • Mucous Membranes: – Tonsils: • If the throat is the portal of entry, there is an acute follicular or membranous tonsillitis, with painful lymphadenopathy – Oral mucous membranes: • Are bright red and there may be deeper red puncta on the palate. – Tongue: • White Strawberry tongue: initially heavily coated tongue, but by the second or third day scattered swollen red papillae give the ‘white strawberry tongue’ appearance. • Red Strawberry Tongue: As the epithelium is shed in 2-3 days, the tongue becomes smooth and dark red before returning to normal. • Fever usually settles in 7–10 days. • Patient is infectious up to 7 days before the symptoms start until 24 hours after starting the first antibiotic tablet.
- 14. White Strawberry Tongue Red Strawberry Tongue
- 16. Clinical Features Contd: • In the severe toxic form: – Eruption is very intense and may be purpuric. – Fever is high – Patient is delirious or comatose. – Myocarditis is often present. • In the septic forms: – Local pharyngeal lesions are severe and – Extensive oedema. – Otitis media – Peritonsillar abscesses
- 17. Differential diagnosis: • Rubella, • Early stage of smallpox, • Drug reactions • Erythema Infectiosum • Epstein-Barr Virus (EBV) Infectious Mononucleosis • Kawasaki Disease • Measles • Toxic Shock Syndrome • Recurrent scarlatiniform erythema caused by Yersinia pseudotuberculosis. • Some staphylococcal infections are accompanied by scarlatiniform erythema
- 18. Complications and co‐morbidities: • Complications due to the toxin: – myocarditis • Complications due to Bacterial invasion of the tissues by local extension or by haematogenous dissemination: – Hepatitis, – Arthritis, – Meningitis and – Osteomyelitis. – Otitis Media – Peritonsillar abscess • Complications due to Allergic Reaction: – Rheumatic fever and – Glomerulonephritis
- 19. Disease course and prognosis: • Good prognosis • Mortality is under 1%. • Second attacks are more frequent in patients in whom early antibiotic control of the initial attack has impaired an adequate immune response
- 20. Investigations: • Throat swab culture of group A β‐haemolytic Streptococcus, • Rapid Antigen Detection Tests: – Done in the doctor's office. – Performed by swabbing the back of the throat. – The bacterial swab is then subjected to either enzymes or acid to extract parts of the Strep pyogenes bacteria. Results are available in 10 to 20 minutes. • Rising antistreptolysin‐O titre • The Schultz–Charlton test: – Blanching of the rash around the point of injection of antitoxin. • Complete Blood Count: – polymorphonuclear leukocytosis.
- 21. Management: • Goals of the treatment of scarlet fever are: – To prevent acute rheumatic fever, – To reduce the spread of infection, – To prevent poststreptococcal glomerulonephritis and suppurative sequelae (eg, adenitis, mastoiditis, abscesses, cellulitis), and – To shorten the course of illness.
- 22. Symptomatic Treatment: • Paracetamol or Ibuprofen for fever • Rest and hydration • Stay away from nursery, school or work for 24 hours after starting the antibiotic. • Avoid sharing utensils and fomites • Avoid contact with at risk patients for e.g. immunocompromised patients
- 23. Specific Treatment: • Penicillin remains the mainstay of antibiotic treatment of scarlet fever and should be given in full dosage for 10 days as soon as the diagnosis is suspected
- 24. Future Topic to be discussed: • Staphylococcal Scalded Skin Syndrome. Previously Discussed Topics: • Viral warts and Anogenital warts • Epidermodysplasia verruciformis • Mealses • Rubella • Erythema Infectiosum • Roseola Infantum • Infectious Mononucleosis • Cytomegalovirus Infection • Molluscum contagiosum • Toxic Shock Syndrome.