Unusual Presentation of Scarlet Fever with Staphylococcal Abscess- A Case Report

Abstract

Scarlet fever is a bacterial infection characterized by a high temperature and exanthem of acute onset, typically with pharyngitis, and might cause severe complications. We present a case of scarlet fever with sandpaper rash, strawberry tongue, along with an unusual concomitant gluteal abscess. Growth of Streptococcus pyogenes was isolated from a throat swab, and staphylococcus aureus was obtained from the gluteal abscess during the evaluation. Patient improved with appropriate treatment without untoward sequelae.

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Internaonal Clinical and Medical Case Reports Journal
Case Report (ISSN: 2832-5788)
Int Clinc Med Case Rep Jour (ICMCRJ) 2024 | Volume 3| Issue 3
Unusual Presentation of Scarlet Fever with Staphylococcal Abscess- A Case
Report
Kavya R M1, Mohnish Sekar2*
1Department of Dermatology, Chettinad Academy of Research and Education (Deemed to be University),
Chettinad Health City, Rajiv Gandhi Salai (OMR) Kelambakkam, Tamilnadu, India
2Department of Dermatology, Karpaga Vinayaga Institute of Medical Sciences and Research centre, GST Road,
Chinna Kolambakkam, Maduranthagam, Kanchipuram dist, Tamilnadu, India
Citation: Kavya R M, Mohnish Sekar. Unusual Presentation of Scarlet Fever with Staphylococcal Abscess- A
Case Report. Int Clinc Med Case Rep Jour. 2024;3(3):1-9.
Received Date: 01 March, 2024; Accepted Date: 05 March, 2024; Published Date: 07 March, 2024
*Corresponding author: Mohnish Sekar, Department of Dermatology, Karpaga Vinayaga Institute of Medical
Sciences and Research centre, GST Road, Chinna Kolambakkam, Maduranthagam, Kanchipuram dist, Tamilnadu,
India
Copyright: © Mohnish Sekar, Open Access 2024. This article, published in Int Clinc Med Case Rep Jour
(ICMCRJ) (Attribution 4.0 International), as described by http:// creativecommons.org/licenses/by/4.0/.
ABSTRACT
Scarlet fever is a bacterial infection characterized by a high temperature and exanthem of acute onset, typically
with pharyngitis, and might cause severe complications. We present a case of scarlet fever with sandpaper rash,
strawberry tongue, along with an unusual concomitant gluteal abscess. Growth of Streptococcus pyogenes was
isolated from a throat swab, and staphylococcus aureus was obtained from the gluteal abscess during the
evaluation. Patient improved with appropriate treatment without untoward sequelae.
Keywords: Scarlet fever; Sandpaper rash; Strawberry tongue; Scaly rash
INTRODUCTION
Scarlet fever, also called scarlatina, is caused by group A beta-hemolytic streptococcus (GABS), mainly
transmitted through nasal droplet or direct contact with the skin or secretions of infected patients[1]. Most cases
occur in children aged 5–15 years of age with a seasonal predilection for winter and spring[2]. The prevalence and
morbidity associated with scarlet fever have decreased due to the advent of antibiotics. We present one such
patient of scarlet fever, along with a concomitant gluteal abscess from our practice. We have also attempted to
explain all the clinical features, including atypical presentations in brief.
CASE REPORT
A 9-year-old boy presented with a widespread scaly rash with a brush-like texture on the touch associated with
itching. The rash initially started over the ears and progressed to the trunk, groin and extremities for two days,
along with a history of fever, sore throat, cough, and cold for seven days. The patient also complained of painful
swelling over the gluteal region for four days, with a history of applying turmeric and Kumkum on their own,

Internaonal Clinical and Medical Case Reports Journal
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which is a common practice in South India among rural population. There was no history of atopy. Examination
revealed a generalized pinhead-sized, skin-coloured papular exanthem with desquamation, rough in texture
present over the ear lobules, neck, trunk, upper extremities, groin, and perineum (Figure 1). There was also a
fluctuant abscess 4x3cm with few pustules and discolouration over the surface due to the application of
condiments over the left gluteal region (Figure 2). An increase in temperature and tenderness was elicited on
palpation. A general physical examination revealed a temperature of 101°C. Mucosal examination revealed
papillar hypertrophy over the dorsum of the tongue, suggestive of strawberry tongue, and mucosal erythema over
the buccal mucosa, palatoglossal arch and pharyngeal wall (Figure 3). Investigations revealed leucocytosis with
neutrophilia and raised ESR. Throat culture was positive for streptococcus pyogenes. Incision and drainage of the
gluteal abscess was done, and purulent material was subjected to culture and sensitivity, which showed the growth
of Staphylococcus aureus. The patient was treated with oral amoxicillin-clavulanate for one week, along with
conservative management of itching, fever and pain with antihistamines, antipyretic and analgesics resulting in
resolution of symptoms in 7 days.
Figure 1: Diffuse skin coloured pinhead sized papular exanthem over trunk, upper extremity and groin.

Internaonal Clinical and Medical Case Reports Journal
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Int Clinc Med Case Rep Jour (ICMCRJ) 2024 | Volume 3| Issue 3
Figure 2: Abscess over gluteal region.
Figure 3: Strawberry tongue
DISCUSSION
GABS, with its distinctive adaptation to the human body, it primarily inhabits the pharynx and saliva. Scarlet
fever caused by Streptococcus pyogenes is transmitted mainly through nasal droplets and direct contact with the
saliva of infected patients. It may also arise from streptococcal wound infections or burns[3]. Scarlet fever is linked
to the exotoxin genes Ssa, SpeA, and SpeC. It is caused by a small number of Streptococcus pyogenes lineages
that are part of group A hemolytic Streptococcus (GAS)[4]. Recent research suggests that there may be an
association between scarlet fever and the opportunistic bacteria Streptococcus sanguis[5]. The incubation period
of scarlet fever ranges from 2 to 7 days. Scarlet fever is usually accompanied by acute pharyngitis presenting with
hyperemia of the pharynx with early pin-point enanthema on the soft palate and enlarged and inflamed tonsils
(with or without purulent exudates) with accompanying white strawberry tongue that turns red in the next couple
of days after losing its covering resembling a red strawberry[6]. A papular exanthem, which spreads
cephalocaudally, follows the pharyngeal symptoms in 1-2 days. The skin is typically rough and abrasive due to
the exanthem, which is prominent at the flexures. The rash subsides with palmoplantar peeling and branny
desquamation in about two weeks[7].
Superantigens secreted by GAS stimulates the immune system, causing an exaggerated hypersensitivity reaction
which results in the distinctive clinical features observed in the scarlet fever[3]. Table 1 enumerates the clinical
features and their charateristics[6-9]
Clinical
features
Strawberry
tongue
Exanthem
Pastia’s lines
Circumoral
pallor
Other
names
Raspberry
tongue
Sandpaper rash
(Because of the
rough sensation
of the skin
Thompson’s
sign
Filatov’s
mask

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caused by the
raised bumps)
“sunburn with
goose pimples,”
“boiled-lobster”
appearance
Appears on
1-2days after
infection
3-4 days of the
infection
3-4days
(seen in
severe cases)
-
Sites
Dorsum of
tongue
Cephalocaudal
spread
Skin folds in
the
neck, axillae,
cubital
fossae, groin
and knees
The rash
usually
spares the
face with
reddish
discoloration
of the cheeks
and a pallor
around the
eyes and
mouth
Cause
Desquamation
of the
keratinized
epithelium of
the filiform
papillae gives
a red and
denuded
appearance
mimicking the
surface of a
strawberry.
This is
intermixed
with persistent,
delayed-type
hypersensitivity
to an exotoxin
Capillary
fragility
unknown

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inflammatory,
and
hypertrophic
fungiform
papillae
(strawberry
seeds).
The tongue
initially
appears like a
“white
strawberry”
because of the
white covering
that covers the
hypertrophied
papillae. After
a few days,
this covering
desquamates,
resulting in the
classic “red
strawberry”
tongue.
variants
1. Miliary (as
1 mm vesicles
with whitish-
yellowish
exudate)
2. Papular (on
knees and
elbows
mainly),
(usually seen
simultaneously
with typical
sandpaper
lesions
-
Pastia lines
are a
hemorrhagic
variant of
exanthema,
representing
the severity
of the
condition.
-

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Atypical
presentation
smooth
macular rash,
exanthema
over the
palmoplantar
surface;
erythema and
swelling of ear
lobes,
extensive
erythroderma,
localized facial
erythroderma
with coarse
exanthema in
the rest of the
body; swelling
involving
eyelids, face,
or the distal
extremities,
perianal
dermatitis; and
urticarial
lesions
-
-
-
Resolution
-
Characteristic
resolution of
the rash with
characteristic
branny
desquamation
and lamellar
(plate-like)
peeling of the
palmar and
plantar aspect
of extremities
-
-

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High fever and evident systemic toxicity are the hallmarks of severe forms of scarlet fever, which can be linked
to significant toxaemia (toxic scarlet fever) and localized, hematogenous dissemination of the organism (septic
scarlet fever)[11].
Complications of scarlet fever are local and systemic in nature. Peritonsillar and retropharyngeal abscesses are
the local complications. Systemic complications are acute rheumatic fever, meningitis, glomerulonephritis,
pneumonia, and endocarditis. Rarely, scarlet fever can cause the development of splenomegaly, hepatitis, or
gallbladder hydrops[3]. No complications were observed because of the infection in our case.
Our patient also had a gluteal abscess, which was dealt with incision and drainage. Staphylococcus aureus was
isolated in the drained purulent material when subjected to culture and sensitivity testing. There are also reports
of staphylococcal scarlet fever in the literature, which is thought to be a mild form of SSSS or TSS[12]. In our case,
exanthem with enanthema and tongue involvement (hypertrophied papillae) point toward streptococcal scarlet
fever because a strawberry tongue is seen with streptococcal but not staphylococcal scarlet fever[13].
Diagnosis depends on several factors, including a complete history of all clinical symptoms before exanthem, a
positive family history, the location and progression of the lesions, a history of systemic medication, and the child
and their caretakers’ recent travel history[14-17].
A thorough medical history, along with a distinctive clinical appearance, is typically used to make a diagnosis of
scarlet fever diagnosis. A culture of the throat swab should be performed in order to confirm the diagnosis[15,18].
Rapid antigen tests that are more convenient and faster have high specificity—95% or more. Since the sensitivity
of the culture is superior to that of the rapid antigen tests, it is recommended to confirm a negative rapid antigen
test result in children and adolescents with a throat culture[19]. Since the body takes two to three weeks to produce
the antibodies against a streptococcal infection (antistreptolysin O and anti-deoxyribonuclease B), serological
testing, where the antibodies against a streptococcal infection are detected, does not help in diagnosing current
scarlet fever but can be performed when assessing a person with complications from a previous streptococcal
infection[20].
Initiation of antimicrobial therapy at the earliest time is crucial in scarlet fever because it shortens the duration of
the infection and helps to avoid complications. Since an individual loses their contagiousness after receiving
treatment after 24 hours, it prevents disease transmission among the pediatric population.[15,18] Beta-lactam
antibiotics are the recommended treatment for GAS infection because of their safety in children with clinical and
cost effectiveness[19]. Penicillin or amoxicillin, in appropriate dosages and regimens, continue to be the first-choice
antibiotic for treating GAS infections; they appear to be more efficacious than cephalosporins and macrolides. If
the patient is allergic to penicillin, clindamycin or a first-generation cephalosporin may be administered[15].
Oral Amoxicillin clavulanate along with symptomatic treatment was given in our patient, to which he responded
well with the resolution of symptoms in 1 week.
IVIG is the other modality used in patients with complications associated with scarlet fever or in patients with
concomitant toxic shock syndrome because of a lack of specific antitoxic immunity[21].

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Most of the patients who receive timely therapeutic intervention have excellent outcomes. Resolution is usually
seen in 3-6 days, though skin symptoms may require 14-21 days to subside[22]. There was a resolution of both skin
and mucosal features in a week with no untoward sequelae in our case.
CONCLUSION
Scarlet fever is a bacterial infection caused by Streptococcus pyogenes, with clinical presentation ranging from
mild to severe. Though we encountered a gluteal abscess due to staphylococcal origin, we ruled out staphylococcal
scarlet fever from the presence of enanthema and strawberry tongue and throat culture showing a growth of
streptococcus pyogenes. Early detection and management of scarlet fever are essential to prevent local and
systemic complications.
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