Scarlet fever A38

Sydenham, 1676

Acute streptococcal infection(angina tonsillaris) caused by erythrogenic toxin-forming, beta-hemolytic streptococci of the Lancefield Group A. Obligation to report!

β-hemolytic Lancefield Group A Streptococci (over 80 different serotypes, type-specific immunity).

Droplet infection. Transmission, even via a contact person or food, is possible. Entry ports: tonsils, nasopharynx, also wounds.

Streptococcal infections are primarily localised infections. In principle, they do not leave behind any antibacterial immunity. Scarlet fever only produces immunity against one of the pyrogenic erythrogenic toxins (there are 4 different toxins that lead to a respective type-specific immunity). This erythrogenic toxin can only be produced if streptococci carry bacteriophages (also called prophages) in their genome that code for it. A specific immunity is directed exclusively against the toxin produced. If an infection is caused by beta-hemolytic streptococci (predominantly angina tonsillaris, only in rare cases by a soft tissue infection = wound scarlet fever), the classic picture of scarlet fever develops if immunity to scarlet toxins is lacking. If immunity is already established, only streptococcal angina will develop. As there are several different toxins, multiple scarlet reinfections (up to 4) are possible. Erythrogenic toxins belong to the so-called superantigens, which are able to lead to a fulminant T cell proliferation with a broadly diversified cytokine production without specific antigen processing.

In very rare cases, scarlet fever induced by staphylococcal enterotoxins occurs predominantly in children.

Mainly occurring between the ages of 3 and 10.

• General: Incubation period 2-5 days.
• Sudden, highly acute onset with high fever, headache and sore throat, tachycardia, vomiting.
• Pharyngitis, angina tonsillaris, swelling of the cervical lymph nodes. Rare splenomegaly.
• Skin lesions (day 2-3): Exanthema, possibly delayed by days. Usually begins in the groin, the thigh triangle or the flexion sides of the arms. Also head, neck, trunk, extremities. The face often shows a butterfly-like distributed redness. Characteristic is a perioral non-binding zone (Facies scarlatinosa).
• Otherwise there are pale, later red, slightly raised, densely packed papules the size of a pinhead (see also Miliaria scarlatinosa).
• Often reduced capillary resistance. The Rumpel-Leede test is positive. In severe cases, flat hemorrhages may occur.
• Mucous membrane changes (day 3): spotty enanthema on the soft palate. Removal of the coating of the tongue (the entire surface of the tongue appears homogeneously red, free of coating in the case of swollen papillae = raspberry tongue).
• Subicterus may be present.
• Decay phase (day 5-7): The exanthema and angina tonsillaris, which have meanwhile flaked and itched, subside with lytic temperature reduction. Scaling: ragged (corneolytic - as after sunburn - scales can be peeled off the skin as a fine translucent film) flaking of the skin on the auricles, face, trunk and extremities. Coarse lamellar desquamation of palmae and plantae.
• After 2-3 months telogenic effluvium, possible formation of transverse furrows of the nails(Beau-Reilsche-cross furrows) of the nails.

Leukocytosis: 15.000-40.000 leukocytes/μl, later eosinophilia 5-10%.

Clinical, pathogen detection, antistreptolysin titre (AST) increase (at the earliest 8-14 days after a fresh infection, baseline and control values), Dick test, eradication phenomenon.

• Measles
• Rubella
• scarlatiniform drug exanthema
• infectious mononucleosis
• Adeno- and Coxsackie virus infections
• Toxin Shock Syndrome

Fulminant courses, see below toxic scarlet fever, septic scarlet fever. Otitis, sinusitis, myocarditis, glomerulonephritis, polyarthritis.

• Penicillin: Penicillin V (e.g. isocillin) 3 times/day 0,4-1,2 million IU p.o. (infants: 0.2-0.6 million IU/day) over at least 10 days. If reliable intake is not guaranteed, benzathine-penicillin (e.g. tardocillin) once 0.6 million IU or 1.2 million IU i.m. In case of severe course or complications Penicillin G (e.g. Penicillin Grünenthal) 10-20 million IU/day i.v.
• For penicillin allergy: erythromycin (e.g. erythrocin) 3 times/day 500 mg p.o. (children 40 mg/kg bw/day) or clindamycin (e.g. sobelin) 4 times/day 150-450 mg p.o. Alternatively cephalosporins like cefadroxil (e.g. cedrox) 1 time / day 2 g or cefuroxime (e.g. Elobact) 2 times/day 250 mg p.o. for at least 10 days.

Notice! Co-treatment of other children living in the household is recommended due to possible serious complications (endocarditis, glomerulonephritis, minor chorea, rheumatic fever)!

Good with early therapy. Letality < 0.5%. Formation of antitoxic antibodies against the specific erythrotoxin in the course of scarlet fever. Also formation of specific antibacterial antibodies.

• In the presence of a type-specific antibacterial immunity: No clinical disease after streptococcal contact, independent of the presence of antitoxic antibodies.
• In the absence of type-specific antibacterial immunity and the presence of antitoxic antibodies: Streptococcal pharyngotonsillitis following contact with streptococci.
• In the absence of the typical specific antibacterial immunity and antitoxic antibodies: angina, streptococcal angina and scarlet fever after streptococcal contact.

1. Hedrick J (2003) Acute bacterial skin infections in pediatric medicine: current issues in presentation and treatment. Paediatr Drugs 5(Suppl 1): 35-46Mun
   SJ et al (2019) Staphylococcal scarlet fever associated with staphylococcal enterotoxin M in anelderly
   patient. Int J Infect Dis 85:7-9.
2. Sydenham T (1676) Observationes medicae circa morborum acutorum historiam et curationem. Londini, G. Kettilby, p. 387