Scarlet Fever

Dear Lisa,

My 3 year old daughter had this weird looking rash on her entire body. It looked like goose bumps. She was also very pale. She had enlarged lymph nodes on her neck. The doctor said it was probably scarlet fever and did a throat swab. She did not have strep throat, was the result. She was on antibiotics. Could it still have been scarlet fever?

Two days after we completed the meds, she started a new rash, red spots this time. I brought her in and the doctor said she had an ear infection and a cold. She is again on antibiotics. Now, we just discovered 2 small lymph nodes on the back of her neck, just below the hairline. Could these be related to the cold and infection? We have a follow-up to make sure the ear infection is gone. Meanwhile, please reassure me!

“Please reassure me”

Dear “Please reassure me”,

Scarlet Fever is caused by Group A beta-hemolytic Streptococcal infections. It presents with an abrupt onset of high fever, abdominal pain, vomiting, sore throat, headache and malaise. A fine, sandpaper-like rash occurs 12 to 48 hours later. This rash first appears under the arms, around the neck and in the groin area before it becomes generalized. The rash which is referred to as Scarlatina is caused by exotoxins produced by one of the strains of Group A Streptococcal bacteria. (1). Strep infections can also cause middle ear infections, Sinusitis, Peritonsillar abscess, Cervical Adenitis and skin infections. (1)

Although Strep is the most common cause of a Scarlatina rash, an infection with certain strains of Staphylococcus may also cause Scarlet Fever. When Scarlatina is caused by a Staph infection the rash is usually tender or painful which is not the case for Strep Scarlet Fever. (2)

The test used to determine if your child has a Strep infection is a throat culture. Health professionals use the throat culture to diagnose Strep infections because it is difficult to differentiate a viral throat infection from a Strep infection simply through visual inspection. (1, 3) The specimen is obtained from vigorous swabbing of the tonsils and the back of the throat with a cotton tipped swab. If the swab and testing is performed correctly, a symptomatic person infected with group A beta hemolytic strep will have a positive result.

False negative cultures can occur in less than 10% of symptomatic patients.(1) In other words a child could have a Strep infection and not have it show on a throat culture test in less than 10% of the time. In general, health professionals rely on the results of the throat culture and only consider a false negative if the child’s history and physical examination strongly support a Strep infection. If this is the case a Doctor or Nurse Practitioner may opt to treat a child with antibiotics. Since untreated Strep infections have potential serious complications and long term effects, this is very reasonable and many times a necessary approach.

From my experiences there have been patients that demonstrate the classic presentation of Strep and have negative Strep results. Once treated with antibiotics the Strep symptoms did go away. By no means is this the norm and in most cases the throat swab is accurate. Occasionally throat culture results may not be accurate due to improper technique or lack of patient cooperation. It is fairly common for a child to resist the throat swab and move so much that it is practically impossible to get a good specimen.

Children diagnosed with Strep may have a reoccurrence of Strep Pharyngitis shortly after completing a 10 day course of recommended oral antibiotics. Studies show that 24 % of children treated with Penicillin and 18% of those children treated with Amoxicillin are back in the clinician’s office within three weeks. (4) This may be contributed to missed dosages of medication, re-infection or medication failure. If this occurs a child should be treated with an alternative antibiotic such as a cephalosporin, amoxicillin-clavulanate or dicloxacillin. (1)

In regards to your child becoming ill again after finishing her course of antibiotics, this can sometimes happen. Children with Strep can pass the infection to someone else in the household. The child can become re-exposed and develop Strep again. It is also possible that a child develops a new infection because their body is run down.

It is expected that a child’s cervical lymph nodes (lymph nodes in the neck area) will enlarge during an infection. This reflects the body’s normal response to infections such as Strep or an inner ear infection. As long as you keep on following up with your Doctor, your daughter’s lymph nodes and infection can be monitored and adjustments to her recovery plan made if necessary.

Some of the measures that you can take to help your daughter recover include good hand washing (especially when you are exposed to her secretions) and avoiding the sharing of food, drinks or eating utensils. Refrain from kissing on the mouth when family members are sick, properly dispose tissues that come into contact with saliva or nasal discharge and keep away from other children with known Strep infections.

In addition it is important that your daughter gets the appropriate amount of sleep which ranges from 11 to 13 hours per day for her age. (5) Even though it’s difficult to feed a child when they are sick, try to give her nutritious foods such as fruit, fruit pops, 100% fruit juice, and soup with vegetables.

Your daughter is very fortunate to have a mom who is so concerned about her. Caring for your daughter during her illness, bringing her to see the Doctor, giving her the medication prescribed and keeping follow-up appointments with the Doctor takes a lot of time, patience and strength. It is this patience and strength that will help your daughter get through this illness.

I wish your daughter a speedy recovery.

For more information about topics discussed you can read the following stories on the Pediatric Advice website:

Scarlatina

Strep Throat

References:
(1)American Academy of Pediatrics. Group A Streptococcal Infections. In: Peter G, ed. 1997. Red Book: Report of the Committee on Infectious Disease. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:483-494.
(2)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:180.
(3)Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984:710.
(4)Newsline. The Clinical Advisor. 2006. Feb:17.
(5) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:70.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Sick Children