What are physical findings characteristic of scarlet fever?

Updated: Jun 21, 2019
  • Author: Bahman Sotoodian, MD; Chief Editor: William D James, MD  more...
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The patient usually appears moderately ill. Fever may be present. The patient may have tachycardia. Tender anterior cervical lymphadenopathy may be present.

The mucous membranes usually are bright red, and scattered petechiae and small red papular lesions on the soft palate are often present.

On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). Red, edematous, exudative tonsils (see the image below) are typically observed if the infection originates in this area.

The exudative pharyngitis typical of scarlet fever The exudative pharyngitis typical of scarlet fever. Although the tongue is somewhat out of focus, the whitish coating observed early in scarlet fever is visible.

Generally, the exanthem develops 12-48 hours after the onset of fever, first appearing as erythematous patches below the ears and on the neck, chest, and axilla. The characteristic exanthem consists of a fine erythematous punctate eruption that appears within 1-4 days after the onset of the illness. The eruption imparts a dry, rough texture to the skin that is reported to resemble the feel of coarse sandpaper. The erythema blanches with pressure. The skin can be pruritic but usually is not painful. Dissemination to the trunk and extremities occurs over 24 hours. It is usually more prominent in flexural areas (eg, axillae, popliteal fossae, and inguinal folds). It may also appear more intense at dependent sites and sites of pressure, such as the buttocks., Eventually scarlet macules are seen overlying the generalized erythema (“boiled-lobster” appearance).

Capillary fragility is increased, and rupture may occur. Often, transverse areas of hyperpigmentation with linear arrays of petechiae in the axillary, antecubital, and inguinal areas (Pastia lines, or the Pastia sign) can be observed. These arrays may persist for 1-2 days after resolution of the generalized rash.

Another distinctive facial finding is a flushed face with circumoral pallor. In severe disease, small vesicular lesions termed miliary sudamina may appear on the abdomen, hands, and feet.

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