What have the Rolling Stones got in common with scarlet fever?

A rather apprehensive Christopher enters you consulting room, clinging tightly to his mother’s hand and staring at you with mistrustful eyes. It’s not really surprising, the last time he was here he had diarrhoea and vomiting and he clearly still blames you for it! You flash him a smile and get
straight down to business finding out what is wrong…

Christopher is 3 years old and for the last 2 days he has had a sore throat and a fever and has not been his normal boisterous self. His mum has brought him to see you because he has developed a fine rash on his chest and
abdomen which has made his skin feel very rough and dry, like sandpaper. You manage to get a quick look in Christopher’s throat and see enlarged, slightly purulent tonsils and a bright red “strawberry tongue”. You smile reassuringly at his mother and start to tap away on your computer… you know exactly what this is… you’ve seen the same problem 3 times already this week…

So what is the diagnosis?
Christopher has the classic signs of scarlet fever; a common childhood infection caused by the Group A Beta-haemolytic Streptococcus (Streptococcus pyogenes). Approximately 4,000 cases of scarlet fever are diagnosed each year in the
UK, with 80% occurring in children under 10 years old.

Clinical Features
• Fever
• Sore throat
• Headache
• Nausea and vomiting
• Generalised “pin prick” rash spreading from chest and abdomen to other parts of the body
associated with a dry sandpaper feel
• Strawberry tongue

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The UK is currently experiencing a bit of an epidemic of
infections caused by the Group A Beta-haemolytic Streptococcus including scarlet fever, tonsillitis, cellulitis, osteomyelitis and septic arthritis, puerperal sepsis and even necrotising fasciitis. It seems like every other report I
authorise out to primary care these days is a throat swab growing a Group A Beta-haemolytic Streptococcus. 

So what needs to be done for these children?
 
Investigations
• Throat swab for Group A Beta-haemolytic Streptococcus culture

Treatment
Antibiotic treatment is recommended for scarlet fever in order to prevent secondary complications such as invasive
Group A Streptococcus (iGAS) infection, rheumatic fever and
post-streptococcal glomerulonephritis. Antibiotics also reduce the duration of infectivity of the patient.

Click for larger image

The term iGAS is used to describe any infection where Group A Beta-haemolytic Streptococcus is isolated from a normally sterile site. The most common iGAS infections are:
• Necrotising fasciitis
• Osteomyelitis
• Septic arthritis
• Cellulitis
• Puerperal sepsis

Infection Control Precautions
Scarlet fever is highly infectious and outbreaks do occur. If
antibiotics are given the infectious period is only 24 hours, however if no antibiotics are given the patient can be infectious for up to 3 weeks.

Children with scarlet fever should not return to nursery or
school until at least 24 hours after starting appropriate antibiotics. Group A Beta-haemolytic Streptococcus can be spread by direct contact or via droplets from the upper respiratory tract. Good hand hygiene is the most important aspect of preventing transmission of the bacteria. 

Prognosis and Complications 
With antibiotic treatment temperatures return to normal within 24 hours and complications are rare. Untreated upper respiratory tract infection with Group A Beta-haemolytic Streptococcus can progress to invasive infection, especially if it occurs in combination with chicken pox (Varicella Zoster). Rheumatic fever or glomerulonephritis may occur 1-5 weeks after scarlet fever in 3% of untreated patients.

Is this old fashioned disease making a comeback? 
Scarlet fever is not a new disease nor is its overall prevalence on the increase; we are just currently experiencing a routine epidemic. Sir William Osler (regarded by many as the father of modern medicine) described
scarlet fever in his 1892 book, The Principles and Practice of Medicine as, “an infectious disease characterised by a diffuse exanthema and angina [ye olde term for pain] of variable
intensity”. He recognised that it could occur either sporadically or in epidemics and usually affected children aged between 1 and 10 years old. 

Although the cause wasn’t known at the time it was proposed that it might have something to do with the “streptococci”  commonly found in the “glands and areas of suppuration [pus]” as well as occasionally in blood. Treatment in 1892 was that “the child should wear a light flannel night-gown and the bed clothing not be too heavy. The diet should consist of milk, broths, and fresh fruits, and water should be freely given” but then mortality was “5-10%
in mild epidemics and 20-30% in the very severe”! 

Sir William Osler also advised caution to his clinical colleagues because of the recognised ability of clinicians and nurses to carry the infection to “persons at a distance” to the original case. Clearly, the importance of infection control was recognised then, so nothing much has changed in the last 130 years… except perhaps the mortality due to the discovery of antibiotics for treatment!

What are the key messages?

1. Scarlet fever is a common bacterial infection in children under 10 years old, caused by the Group A Beta-haemolytic Streptococcus and often occurs as epidemics
2. Antibiotic treatment, with Penicillin or Azithromycin, is indicated to reduce the incidence of serious complications as well as reducing the infectious period
3. Children with scarlet fever should be excluded from nursery or school until they have had 24 hours of appropriate antibiotics to prevent spread of this infection

So what have the Rolling Stones got in common with scarlet fever?

Answer:
A strawberry tongue!



Reference:
Interim guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings. Public Health England, April 2014

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