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Clinical Opal - A child with a rash

17 August 2023 - Dr Simon Morgan

Your next patient is Frankie, a 5 year old girl, who is brought in by her mother Nora. Frankie has been unwell for the past 48 hours with fever, sore throat and headache. The previous day Nora noticed a rash over Frankie’s neck and chest which has since spread over the rest of her body.

On examination, Frankie looks miserable with a temperature of 38.1C and HR of 110. She has a red throat and tender cervical lymphadenopathy, and a classic ‘strawberry tongue’. She has a red rash over her body which feels rough to palpation.

strawberry tonguePhoto credit: From Wikimedia Commons

What is the most likely diagnosis for Frankie?

 

Frankie has clinical features typical of scarlet fever.

Scarlet fever is a childhood exanthem related to a toxin-producing strain of Streptococcus pyogenes (Group A strep). Scarlet fever occurs most commonly in children aged 4-8 years following a streptococcal throat or skin infection.   

Clinical features of scarlet fever include a sudden high fever followed by a distinctive rash. The rash usually starts as blotchy red patches below the ears, neck, chest, armpits and groin before spreading to the rest of the body over 24 hours. As skin lesions become more widespread, they can look like sunburn with goose pimples with a rough sandpaper-like feel.1 

Other clinical features include circumoral pallor and strawberry tongue.

With appropriate treatment, scarlet fever usually follows a benign course, but can have serious sequelae such as rheumatic fever, or invasive GAS (iGAS). Presentations of iGAS includes sepsis as well as severe localised infections such as necrotising fasciitis, pneumonia/empyema, meningitis, osteomyelitis and septic arthritis. 

There has been a recent increase in cases of iGAS observed in Australia and internationally. Data from Queensland Health shows more than 350 invasive Strep A cases have been recorded across the state for 2023, a recent insurgance has been attributed to a new strain of group A steptococcal from the UK.

While the overall risk of iGAS in the general population remains low, people at higher risk include household contacts of patients with iGAS; people older than 65, or younger than 5 years; Aboriginal and/or Torres Strait Islander people; people who inject drugs; immunocompromised people; and pregnant and post-partum women.

Recent advice urges GPs to be alert for the signs and symptoms of iGAS and to thoroughly evaluate all patients with a clinically compatible illness. In particular, GPs need to consider iGAS in the higher risk patient who is more unwell than expected with an apparent viral illness. 

iGAS is one of the many topics covered in the 2023 Hot Topics and PACED courses:

 

Hot Topics


References

1.    DermnetNZ website

Dr Simon Morgan
Dr Simon Morgan

Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast.  He also has medical education roles with the RACGP and GPSA.

Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.

Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.

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