Chong Hua Hospital Mandaue

Department of Pediatrics

A 6-year-old Male With A Rash of Possibilities

Presenters: Reactor:
Moreno, Daphne Pearl Dr. Doris Louise Cellona-Obra
Paloma, Ma. Shiela
Pitogo, Patrizia NIcole R.
Rejulio, Crystal Mae
Santos, Ma. Fleurellei
 Chong Hua Hospital - Mandaue
Department of Pediatrics

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 Chong Hua Hospital Mandaue
Department of Pediatrics

A 6-year-old Male With A Rash of Possibilities

Presenters: Reactor:
Moreno, Daphne Pearl Dr. Doris Louise Cellona-Obra
Paloma, Ma. Shiela
Pitogo, Patrizia NIcole R.
Rejulio, Crystal Mae
Santos, Ma. Fleurellei
 Objectives:

To present a case of scarlet fever in a pediatric patient and highlight the diagnostic
challenges posed by its overlapping features with other febrile exanthematous
illnesses.
To describe the clinical presentation, physical findings, and diagnostic workup in a
child with fever and generalized erythematous rash.
2. To identify and differentiate scarlet fever from other common causes of
febrile rashes in children such as Kawasaki disease, measles, dengue fever, and
Henoch-Schönlein purpura.
To discuss the epidemiology, pathophysiology, diagnostics, treatment,
Patient Profile
Patient K.C.P

● 6 years old
● Male
● Born on September 1, 2018
● Filipino
● Roman Catholic
● Residing at Mandaue City
Cebu

Chief Complaint: fever rash

History Taking
Prenatal History

● Mother 24 years old, G1P0

● First PN at 4 weeks AOG with regular visits
thereafter
● No maternal illness
● Compliant to prenatal medications
● Nonsmoker, nonalcoholic beverage drinker
● No history of illicit drug use
Natal History

● Delivered at 39 weeks via Vacuum-assisted Delivery at CDUH

● Good cry and activity, appeared pink at birth
● No fetomaternal complications
● Birth Weight is 3250g, AGA
● Given BCG, Hep B Vaccine, Eye prophylaxis & Vitamin K
● Newborn Screening Normal
Postnatal History

● Patient was exclusively breastfed for 3 months

● Mixed feeding thereafter
● Complementary feeding at 6 months old
● Diet: mostly home-cooked meals and carenderia-bought food
 Immunization
1st Dose 2nd Dose 3rd Dose 1st Booster 2nd Booster None

BCG ✔

DTP ✔ ✔ ✔ ✔

OPV/IPV ✔ ✔ ✔

Hib ✔ ✔ ✔

Hep B ✔ ✔ ✔

Pneumococcal ✔ ✔ ✔

Rotavirus ✔ ✔

℅ Local Health Center

 Immunization
1st Dose 2nd Dose 3rd Dose 1st Booster 2nd Booster None

Varicella

AMV ✔

MMR ✔ ✔

FLU

Other:
Meningococcal
Hep A
Japanese B
Encephalitis
Typhoid
HPV

℅ Local Health Center

Developmental Milestones

● At par with age

● Currently a Grade 2 student
● No difficulties in school
Past Medical History

● Patient is non-diabetic and

non-asthmatic.
● No history of congenital anomalies

● History of UTI last 2019-not admitted.

● No previous hospitalization/surgeries
Family Medical History

● (+) Hypertension
● (+) Diabetes
● (+) Bronchial Asthma
● (+) Goiter
Personal & Social History

● Currently a Grade 2 student at a public school.

● Lives with his family in a 2-storey house made up of
mixed materials
● Diet: home-cooked and carenderia-bought meal
● Fluids: milk and water
● No known food and drug allergies
Personal & Social History

● Extracurricular activities: plays basketball and

plays outside with neighbours
● Sleep: 8 hours a day (10pm-6am), undisturbed, well
rested
● Screentime: >3hrs but <6hrs
● No changes in urinary patterns and bowel
movement
History of Present Illness
1 week PTA

● onset of occasional dry cough

○ no medications taken
○ no consult done
History of Present Illness
2 days PTA

● onset of fever- tmax 39.5C

○ Paracetamol- temporary relief
● associated with:
○ sore throat and odynophagia
○ decreased appetite
○ decreased activity
○ abdominal pain
○ generalized flush skin, warm to touch
■ cold bath- no relief
● occasional dry cough still noted
History of Present Illness
1 day PTA

● persistence of fever- tmax 39C

○ Paracetamol- temporary relief
● now associated with:
○ vomiting
■ 3 episodes- watery with phlegm, ~½ cup/episode
○ generalized rash, pruritic, erythematous
■ started on the head and neck then to the trunk
and extremities
● persistence of sore throat and occasional dry cough
History of Present Illness
Morning PTA

● loose watery stool

○ 2 episodes
○ non-bloody, nonmucoid, non-foul smelling
○ bristol type 7
● persistence of symptoms prompted consult and
subsequent admission
Review of Systems

GENERAL fever, decreased activity, decreased appetite

SKIN generalized erythematous, pruritic rash

THROAT/MOUTH sore throat, odynophagia

RESPIRATORY dry cough

GIT Abdominal pain, loose watery stool, vomiting

Review of Systems
Physical Examination
Physical Examination
General Survey: AWAKE, ALERT, WEAK LOOKING
Vital Signs:
BP: 100/60
HR 149
RR 30
TEMP: 38.1
O2SAT: 97%
Anthropometrics:
WT: 24.5 kg (z score: 1)
HT: 120cm (z score: 1)
BMI: 17 kg/m^2 (normal)
Physical Examination
Physical Examination
Physical Examination
Physical Examination
Physical Examination
● Warm to touch with good skin turgor and mobility
● (+) generalized erythematous, pruritic, fine papular rash, sandpaper like
Skin
texture, blanches on pressure
● (+) pale nail beds

Head
● Normocephalic, symmetrical, and atraumatic.
● No lesions noted on the scalp

Eyes
HEENT ● Anicteric sclerae, pink palpebral conjunctivae equally round, reactive to
light with intact red orange eyes reflex
● Corneal reflex was intact. Full EOM was observed
● No discharges, ptosis, and nystagmus noted
Physical Examination
Ears
● Symmetrical, tympanic membranes were intact with cons of light
● No ear deformities, tenderness, masses, and discharges
● Rinne and weber’s test were not performed

Nose
● External nose were symmetrical with a septum located at the midline
● No nasal flaring was noted
● No sinus tenderness and epistaxis were noted
HEENT

Mouth and Throat

● (+) slightly dry lips
● (+) Grade III tonsils, nonexudative, hyperemic
● (+) hyperemic tongue with erythematous raised papillae
● Neck was flexible and not rigid
● Trachea was midline
● No cervical lymphadenopathy, acanthosis nigricans, venous engorgement, lesions,
and masses were noted.
Physical Examination

● Thorax was symmetric without deformities and masses

Chest and
Lungs
● No retraction
● Equal chest expansion, clear breath sound

● Point of maximal impulse was at 5th intercostal space on the left

midclavicular line
CVS ● Adynamic precordium, distinct heart sounds
● Regular rate and rhythm
● No thrills, heaves, and murmurs noted
Physical Examination
● Flat, non distended with no visible bulges or masses, with even
pigmentation, no rashes, striae, scars or lesions
● Umbilicus is midline and inverted with no signs of hernia or
inflammation
Abdomen ● Normoactive bowel sounds with 18 clicks/mins, no bruit or friction rubs
● Generally tympanitic, no shifting dullness
● Soft, nontender, no organomegaly
● (-) Murphy’s sign, (-) Rovsing's sign, (-) Mcburney’s sign, (-) Cullen Sign, (-)
Turner’s Sign
Physical Examination
● Grossly male
Genitourinary
● (+) KPS, bilateral

● Extremities were symmetrical

● Full range of motion and locomotion
Musculoskeletal
● slightly cool feet, pale soles
● CRT 2-3 secs

● GCS 15
● The patient was awake, alert, and cooperative
Neurologic ● Deep Tendon Reflexes and Primitive Reflexes were intact (+2)
● Sensory: Light touch, position, and vibration were intact
● Motor: No spasticity, flaccidity noted with good muscle bulk and tone
Physical Examination
CRANIAL NERVES

I ● Able to identify familiar scents

● Pupils were equally round and reactive to light. Positive direct and consensual reflexes
II
were noted

III, IV, ● Full extraocular movement on both eyes

and VI ● No Ptosis, diplopia, or nystagmus

● Temporal and masseter strength intact

V

● No facial asymmetry
VII ● Can crease forehead
● (-) flattened nasolabial folds
Physical Examination
CRANIAL NERVES

VIII ● Hearing intact bilaterally, weber and rinne test not done

IX, X ● Present gag reflex

● Strength in sternocleidomastoid and trapezius muscles 5/5

XI
● (+) Turn head with resistance

● Tongue midline at rest and upon protrusion

XII
Physical Examination
Salient Features: Pertinent Positives
History Physical Exam
● 6yo, male, Filipino - weak looking
● 7 days PTA: occasional dry cough - febrile, tachycardic, tachypneic
● 2 days PTA: high grade fever
○ decreased activity Skin: (+) generalized erythematous, pruritic, fine papular rash,
○ decreased appetite sandpaper like texture, blanches on pressure
○ sore throat (+) pale nail beds
○ dry cough HEENT: slightly dry lips
○ abdominal pain Grade III hyperemic tonsils, nonexudative
○ flushed skin
hyperemic tongue with erythematous raised papillae
● 1 day PTA: vomiting; rash
● Day of adm: LWS x 2 GUT: (+) KPS, bilateral
● Exposure: Ext: CRT 2-3 secs
○ (+) 2 neighbors with fever & rash slightly cool feet
○ (+) mosquitoes pale soles
Salient Features: Pertinent Negatives
History Physical Exam
- No dyspnea Skin: Palmar and plantar sparing of rashes
- No arthralgia HEENT: (-) conjunctival injection
- No photophobia (-) discharges: eyes, nose, ears
- No conjunctivitis nor coryza (-) cervical LAD
- No headache, dizziness C/L: (-) adventitious lung sounds
- No HHM with similar symptoms CVS: DHS, no murmur
Abd: flat, NBS, nontender, nondistended
GUT: no penile discharge
CNS: No neurologic deficits
Primary Impression:
Scarlet Fever
● 6 yo
● After an incubation period of 2-5 days:
○ rapid onset of fever & sore throat
● enlarged, erythematous tonsils
● Rash
○ within 24-48 hr after onset of symptoms
○ generalized, erythematous, pruritic, blanching
○ from the head & neck down to trunk & extremities, palmar/plantar sparing
○ sandpaper-like texture
● abdominal pain, vomiting
● Strawberry tongue
● circumoral pallor
● Modified Centor scoring: 3 points
Clinical Formulation
Differential Diagnosis
Rule In Rule Out

High-grade Fever + (-) Bilateral conjunctival injection, non- exudative

✅ strawberry tongue (-) erythema, and induration of the palms & soles
✅ generalized, erythematous maculopapular rash with periungual desquamation
Incomplete (-) cervical LAD
Kawasaki Disease Asian, male
common in <5 yo

(+) high grade fever Rash in measles is nonpruritic and not sandpaper
(+) generalized maculopapular rash like
- spreads cephalocaudally (-) 3C’s:Cough, Coryza, Conjunctivitis
Measles (Rubeola)
(+) vaccinated
Differential Diagnosis
Rule In Rule Out

(+) fever, rash, abdominal pain, vomiting Rash in dengue: islands of white in a sea of red
(+) exposure to mosquitoes - rash appeared too early after onset of fever
no arthralgia, myalgia, nor retro-orbital pain
Dengue Fever

Asian, male rash is not a palpable purpura

90% of cases happen in 3-10 yo - classically affects buttocks and legs
preceded by an upper respiratory infection (dry cough 7 - nonpruritic
Henoch Schonlein days PTA) No musculoskeletal involvement
Purpura (+) GI symptoms: abdominal pain, vomiting, loose No subcutaneous edema
watery stools No neurologic symptoms
ER management (HOD 1)
Course in the Wards (Day 1-3)
Course in the Wards (Day 1-3)

day 2
Case Discussion
 ETIOLOGY
● Group A streptococci
○ Gram positive coccoid-shaped bacteria in chains
○ Catalase and oxidase negative
○ Complete (beta-hemolytic) hemolysis on blood agar
○ Bacitracin sensitive
○ produce superantigen exotoxins (erythrogenic toxins)
■ Erythematous sandpaper-like rash
■ Strawberry tongue
 EPIDEMIOLOGY
● Humans - natural reservoir of GAS
● Pharyngeal infections
○ highest in children 5-15 years of age
○ Young school-age children
● Airborne salivary droplets and nasal discharge; close proximity
○ Schools, military barracks, homes
● Incubation period: 2-5 days
 PATHOPHYSIOLOGY
●
 CLINICAL MANIFESTATIONS
● Group A streptococci pharyngitis + characteristic rash
○ Pyrogenic toxin (erythrogenic toxin)-producing GAS
● Rash appears 24-48hr after onset of symptoms
○ Neck > trunk > extremities
○ Diffuse, finely papular, erythematous eruption —> bright red
blanching discoloration
○ Creases of the elbows, axillae, and groin (Pastia lines)
● Skin: goose pimple appearance and feels rough
● Rash fades and followed by desquamation after 3-4days
● Tongue: swollen papillae > becomes prominent after desquamation
(strawberry tongue)
 Childhood Rashes
1ST DISEASE 2ND DISEASE 3RD DISEASE
Measles Scarlet Fever German Measles (3-day Measles)
Rubeola S. pyogenes Rubella

Fever, Rash (Cephalocaudal) Strawberry tongue, sore throat, Maculopapular (Cephalocaudal)

occurring at the peak of fever painful lymph nodes, flushed cheek, (+) post-auricular LAD
3Cs: Cough, coryza, conjunctivitis Sandpaper-like rash Forschheimer spots
Koplik spots
 Childhood Rashes
5TH DISEASE 6TH DISEASE
Erythema Infectiosum Exanthem Subitum/Roseola
Parvovirus B19 HHV-6

Slapped-cheek syndrome 3-day fever followed by rash

Nagayama spots
 Childhood Rashes
KAWASAKI DISEASE MULTISYSTEM INFLAMMATORY DENGUE FEVER
SYNDROME (MIS-C)
Unknown cause Unknown cause Flaviviridae

Any form of rash but rarely vesicular, (+) SARS-CoV-2 or exposure to Blanching rash during the 1st
Strawberry tongue, painless person with the virus within 4 1-2 days of fever (Herman’s
lymphadenopathy, Conjunctivitis, Hand weeks of the onset of symptoms rash)
changes Kawasaki-like features but do not Biphasic fever, myalgia
need to fulfill KD criteria
 Culture of a throat swab

Streptococcal Rapid
DIAGNOSTICS Anti-DNase B
antigen Detection test

Molecular Assays Anti-Streptolysin O assay

(eg. Isothermal loop
Amplification)
 DIAGNOSTICS
● Advantage:
○ Effective for documenting the presence of GAS
1. CULTURE OF A ○ Confirming the clinical diagnosis of acute GAS pharyngitis.
○ Sensitivity of 90-95% for detecting the presence of GAS in the pharynx.
THROAT SWAB ● Disadvantage:
○ Delay in obtaining the culture result.

● Advantage:
○ For the identification of GAS directly from the throat swabs
2. STREPTOCOCCAL ○ Speed in providing results, often < 10-15 minutes.
RAPID ANTIGEN ○ Excellent specificity of >95%
DETECTION TEST ● Disadvantage:
○ However, the sensitivity is 80-90% which is lower compared to the blood agar
plate culture.
 DIAGNOSTICS

● Advantage:

3. GAS MOLECULAR ○ Sensitivity up to 100% and specificity >96% compared to culture or PCR
○ The benefit of faster results, sometimes <10 min, ensures more expedited
ASSAYS initiation of appropriate antibiotic therapy for patients with GAS pharyngitis.
(ISOTHERMAL LOOP ● Disadvantage:
AMPLIFICATION) ○ Very high sensitivity may lead to higher numbers of positive results
○ May contribute to identification of more patients with asymptomatic GAS
colonization and unnecessary antibiotic therapy.
 DIAGNOSTICS
● Advantage:

4. ANTI- ○ Allows retrospective diagnosis of GAS infection

○ Feeble after a skin infection
STREPTOLYSIN O ● Disadvantage:
TITER ○ Not specific for Group A infection

● Advantage:
○ Generally present after either skin or throat infections
5. ANTI-DNASE B
TREATMENT
GOALS

Prevent Acute Rheumatic fever

Shorten the clinical course of

the illness

Reduce the transmission of

the infection to others

Prevent suppurative complications

 TREATMENT
● Oral Penicillin V
○ If <60 lbs: 250mg/dose BID or TID x 10 days
1st Line ○ If >60 lbs: 500mg/dose BID or TID x 10 days
● Benzathine Pen G
○ If <60 lbs: 600,000 IU as single dose IM
○ If >60 lbs: 1.2M IU as single dose IM

With Penicillin ● Narrow Spectrum Cephalosporin for 10 days

Allergy ● Oral Clindamycin for 10 days
● Oral Macrolide for 10 days (except Azithromycin
which is given only for 5 days.
 Acute Streptococcal
Acute Rheumatic Fever
Glomerulonephritis

COMPLICATIONS

Poststreptococcal Pediatric Autoimmune

Reactive Arthritis Neuropsychiatric Disorders
(PSRA) Associated with Streptococcus
pyogenes (PANDAS)
COMPLICATIONS

ACUTE RHEUMATIC
FEVER
COMPLICATIONS
POSTSTREPTOCOCCAL REACTIVE ARTHRITIS ACUTE RHEUMATIC FEVER
● Onset of acute arthritis following an episode of ● Jones Criteria (2 Major or 1 Major + 2 Minor)
GAS pharyngitis in a patient whose illness does ● Fever is a minor criteria
not fulfill the Jones Criteria for diagnosis of acute ● Carditis is a major manifestation
RF
● Fever is unlikely
● Very small proportion have been reported to
develop subsequent valvular heart disease.
● Usually involves the large joints and may also ● Usually involves the large joints
involve small peripheral joints and nonmigratory ● Migratory Polyarthritis
● Latent period may be considerably shorter ● Latent period is usually 14-21 days
(usually 10 days)
PROGNOSIS
The prognosis for appropriately treated GAS pharyngitis is excellent and complete
recovery is the rule.

When therapy is instituted within 9 days of the onset of symptoms and continued
for the full course, acute RF is almost always prevented.

There is no comparable evidence that acute poststreptococcal

glomerulonephritis can be prevented once pharyngitis or pyoderma with a
nephritogenic strain of GAS has occurred.
Thank You!