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Patient Story

A 7-year-old boy is brought to the pediatrician’s office with a rough red rash on his trunk (Figures 28-1 and 28-2) along with fever and a sore throat. The sandpaper rash and signs that are consistent with strep pharyngitis lead the physician to diagnose scarlet fever. The physician explains the diagnosis to the mother and oral penicillin V is prescribed. The boy feels markedly better by the next day and the mother continues to give the penicillin for the full 10 days, as directed, to prevent rheumatic fever.


Sandpaper rash on the trunk and in the axilla of a 7-year-old boy with scarlet fever. (Used with permission from of Richard P. Usatine, MD.)


Scarlatiniform rash comprising small papules and erythema on the trunk of a febrile child with strep pharyngitis. (Used with permission from Richard P. Usatine, MD.)


Scarlet fever is an illness caused by toxin-producing group A β-hemolytic streptococcus (strep) infection. Most commonly, scarlet fever evolves from an exudative pharyngitis.

Strawberry tongue may be observed in patients with scarlet fever and usually develops within the first 2 to 3 days of illness. A white or yellowish coating usually precedes the classic red tongue with white papillae (Figure 28-3).


Sandpaper rash (scarlatiniform) seen prominently on the hand of a child recovering from strep pharyngitis. (Used with permission from Richard P. Usatine, MD.)


  • Scarlet fever is predominately seen in school-age children with no gender predilection.

  • Majority related to strep pharyngitis, with 1 in 10 developing scarlet fever (Figures 28-1, 28-2, and 28-4).

  • Prevalent in late fall to early spring.

  • Strawberry tongue (Figure 28-4) is most commonly seen in children in association with scarlet fever or Kawasaki disease.

  • Can be present with other group A strep infection.

  • In cases of strep, a white membrane through which the papillae are seen can initially cover the tongue followed by desquamation of the membrane (with the appearance as in Figure 28-4).


Strawberry tongue in a child with scarlet fever caused by strep pharyngitis; note marked erythema and prominent papillae. (Used with permission from of Richard P. Usatine, MD.)

Etiology and Pathophysiology

  • Transmission of Streptococcus pyogenes (Group A) (GAS) occurs via respiratory secretions.

  • Virulent GAS incubates over 2 to 7 days. M protein serotypes of GAS are typically more invasive, with greater potential for progression to rheumatic fever ...

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