![]() The use of the rapid strep test with older persons (greater than 45 years) is controversial since they are more likely to be in a carrier state and have a lower prevalence in that age group. The throat culture takes longer (days) and is more specific, and the rapid test is immediate (minutes) and less specific. Testing available to the clinician includes throat culture and the rapid strep test. In cases associated with pharyngitis, lack of a cough, exudates, cervical nodes, temperature, and age (less than 15 years) help determine the likelihood of strep throat. This is known as the CENTOR criterion. After carefully taking a history and physical, the next steps of the evaluation can be considered. When evaluating a person suspected of having scarlet fever, there are several things to consider. After the initial rash begins to resolve, a period of desquamation can occur and last up to two weeks in some cases. This appears as a linear accumulation of papules around pressure points. As the white coating resolves, the papules remain, giving the appearance of a strawberry. Pastia lines are found in the folds of the skin such as the neck, antecubital fossa, and groin. The circumoral area is also spared, making it pallor-like. The “strawberry tongue” begins with a white coating of the tongue with hyperplastic papillae. The trunk, underarms, and groin are affected first, and then it spreads to the extremities. Pustules are more indicative of a local infection such as impetigo or erysipelas. The rash develops within 2 to 3 days after infection but can be delayed up to 7 days. Vesicles are more associated with the “dew on a rose petal” appearance of chickenpox in its initial stages. Also of note, there are no vesicles or pustules present. This lack of confluence is the primary reason it feels like sandpaper. It is distinguished from the macular rash found an allergic reaction by its insidious emergence and lack of confluence of the lesions. The two vectors of infection can both cause scarlet fever and are not distinguishable from one another. The rash itself is a blanching, papular rash. ![]() If there is no pharyngitis, the source of infection can be a wound or burn which is infected with GAS. As a result, fever, sore throat, pain with swallowing, and cervical adenopathy is present. Typically, scarlet fever is associated with acute pharyngitis. The increase has not been explained, but resistant strains of GAS are suspected. Similar increases have been reported in Great Britain. An article on the epidemiology of scarlet fever in Hong Kong reported an increase in the incidence of disease from 3.3/10,000 to 18.1/10,000. This is probably due to the more likely presence of crowded living quarters. The prevalence is higher in undeveloped countries. The difference in rates between children and adults is likely due to the presence or absence of immunity. A decrease in the rate of infection can be attributed to times when school is not in session during the spring and warming temperatures. Multiple studies have reported the emergence of scarlet fever coinciding with the initiation of the school year and the colder temperatures as winter approaches. There is no gender preference for scarlet fever. Non-school-aged children in contact with school-aged children in the same household are also at risk. ![]() ![]() It has been reported that strep throat is responsible for 15 to 30% of all pharyngitis in children aged 5 to 15 years old. Wounds and burns infected with GAS also can cause scarlet fever. It is most commonly associated with bacterial pharyngitis caused by GAS or strep throat. Scarlet fever is a disease of childhood due to ease of transmission in the classrooms and nurseries.
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