What is the treatment for a 14-year-old with a sore throat, tonsils full of exudate, burning tongue, and a facial rash?

Treatment of Scarlet Fever in a 14-Year-Old

This clinical presentation—exudative tonsillitis, sore throat, facial rash, and burning tongue in an adolescent—is classic for scarlet fever (Group A streptococcal pharyngitis with scarlatiniform rash), and requires immediate antibiotic treatment with penicillin or amoxicillin for 10 days after confirmatory testing. 1

Immediate Clinical Assessment

The combination of symptoms strongly suggests Group A Streptococcus (GAS) infection with scarlet fever:

• Tonsillar exudate is one of the four modified Centor criteria indicating increased probability of GAS pharyngitis 1
• Facial rash (scarlatiniform) is pathognomonic for scarlet fever, representing streptococcal toxin-mediated erythema 2, 3
• Burning tongue likely represents "strawberry tongue," a characteristic finding in scarlet fever 2
• The patient meets 3-4 Centor criteria (tonsillar exudate, likely fever, likely tender cervical nodes), indicating a 32-56% risk of GAS infection 1, 4

Required Diagnostic Testing Before Treatment

Do not treat empirically—obtain microbiological confirmation first:

• Perform rapid antigen detection test (RADT) immediately, which has ≥95% specificity for GAS 1, 4
• If RADT is positive, proceed directly to antibiotic treatment 1, 4
• If RADT is negative in this adolescent, confirm with throat culture before withholding antibiotics given the high clinical suspicion with scarlatiniform rash 5
• The presence of a scarlatiniform rash with exudative pharyngitis makes GAS infection highly likely, warranting testing even if some Centor criteria are absent 5, 2

First-Line Antibiotic Treatment

Once GAS is confirmed, initiate narrow-spectrum antibiotics immediately:

• Penicillin V 250-500 mg orally twice or three times daily for 10 days is the first-line treatment due to proven efficacy, no resistance, narrow spectrum, and low cost 4
• Amoxicillin is an acceptable alternative, particularly for improved compliance, but exercise caution in adolescents as concurrent Epstein-Barr virus (infectious mononucleosis) can cause severe rash with amoxicillin 5
• The full 10-day course is mandatory for bacterial eradication and prevention of acute rheumatic fever, which remains a risk in adolescents 1, 5
• If penicillin-allergic, azithromycin 12 mg/kg once daily for 5 days is an alternative (maximum 500 mg/day) 6

Critical Management Points

Antibiotics provide modest symptom relief but prevent serious complications:

• Antibiotics shorten sore throat duration by only 1-2 days, with number needed to treat of 6 at 3 days 1, 4
• The primary benefit is prevention of acute rheumatic fever, peritonsillar abscess, and limiting spread to close contacts 1
• Antibiotics do not prevent acute glomerulonephritis 1

Symptomatic Management (Regardless of Etiology)

Provide aggressive symptomatic relief alongside antibiotics:

• Prescribe ibuprofen or acetaminophen for pain and fever control 4
• Throat lozenges may provide additional relief 1, 4
• Ensure adequate hydration 7
• Counsel that symptoms typically resolve within 1 week 1, 4

Critical Pitfalls to Avoid

Do not miss life-threatening conditions that can mimic streptococcal pharyngitis:

• Rule out diphtheria if the patient is unimmunized or inadequately immunized—look for "bull neck" appearance, inspiratory stridor, or bleeding with swabbing of exudates 8
• Assess for peritonsillar abscess if there is severe unilateral throat pain, trismus, muffled "hot potato" voice, or uvular deviation 9, 10
• Consider infectious mononucleosis if there is generalized lymphadenopathy, splenomegaly, or severe fatigue—do not give amoxicillin if EBV is suspected 5, 2
• Evaluate for epiglottitis if there is drooling, severe dysphagia, or respiratory distress requiring urgent airway management 9

Follow-Up Considerations

• Patients should improve within 48-72 hours of starting antibiotics 7
• If no improvement or worsening occurs, reassess for complications (peritonsillar abscess, retropharyngeal abscess) or alternative diagnoses 9, 10
• Tonsillectomy is not indicated for acute tonsillitis and should only be considered for recurrent infections meeting strict criteria 4