Scarlet feverA38

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, also via a contact person or food, is possible. Ports of entry: tonsils, nasopharynx, also wounds.

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

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

• General: Incubation period 2-5 days.
• Sudden, highly acute onset with high fever, headache, sore throat, tachycardia, vomiting.
• Pharyngitis, angina tonsillaris, pressure-dolent cervical lymph node swelling. Less commonly, splenomegaly.
• Skin lesions (day 2-3): Exanthema, possibly delayed by days. Onset usually in the groin, thigh triangle, or flexor sides of the arms. Furthermore head, neck, trunk, extremities. The face often shows a butterfly-like distributed areal redness. Characteristic is a perioral free zone (facies scarlatinosa).
• Otherwise, there are pinhead-sized, pale, later red, slightly raised, densely packed papules (see also Miliaria scarlatinosa).
• Often reduced capillary resistance. The Rumpel-Leede test is positive. In severe course, planar hemorrhages may occur.
• Mucosal changes (day 3): patchy enanthema on the soft palate. Exfoliation of the tongue coating (thus the entire tongue surface appears homogeneously red, free of coating with swollen lingual papillae = raspberry tongue).
• Subicterus may be present.
• Decay phase (day 5-7): Resolution of the now desquamating and pruritic exanthema and angina tonsillaris with lytic temperature reduction. Desquamation: flaky (corneolytic - as after sunburn - scales can be peeled off the skin as a fine translucent membrane) desquamation of the skin on the auricles, face, trunk and extremities. Coarse lamellar desquamation of palmae and plantae.
• After 2-3 months telogen effluvium, possibly formation of transverse furrows of the nails(Beau-Reilsche transverse furrows) of the nails.

• 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)!

• 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