Scarlet Fever: Prominent Clinical Symptoms
Scarlet fever presents with a distinctive triad of sudden-onset sore throat with severe pain on swallowing, high fever (typically 101-104°F), and a characteristic sandpaper-like rash, most commonly affecting children aged 5-15 years. 1, 2, 3
Cardinal Features
Pharyngeal Manifestations
- Severe sore throat with pain on swallowing is the hallmark symptom, often the first complaint 2, 3
- Tonsillopharyngeal erythema with or without exudates appears in most cases 2
- Palatal petechiae are commonly observed 2
- "Strawberry tongue" develops characteristically—initially white-coated, then progressing to bright red with prominent papillae 1, 2
Fever Pattern
- High fever between 101-104°F (38-40°C) is typical, though absence of fever does not exclude the diagnosis 2, 3
- Fever persists for at least 5 days if untreated 1
- In children under 4 years, fever >38°C occurs in 80% of cases 4
The Pathognomonic Rash
- Sandpaper-like, papular rash is the defining feature that distinguishes scarlet fever from simple streptococcal pharyngitis 1, 5, 6
- Begins on the trunk and spreads to extremities, with particular accentuation in the perineal region 1, 2
- Appears earlier in the illness compared to other exanthematous diseases 1
- Rarely becomes petechial and typically does not initially involve palms and soles, helping differentiate it from Rocky Mountain Spotted Fever 1, 2
- Early desquamation is possible 1
Additional Common Symptoms
Systemic Features
- Headache is frequently reported 3, 7
- Nausea and vomiting, particularly in younger children 3, 7
- Cervical lymphadenopathy, usually unilateral, occurs in approximately 70% of cases 1, 4
Age-Related Variations
- Children under 4 years represent 57% of cases and present with higher fevers but may have less typical presentations 4
- Tonsillar exudate appears in only 24% of cases, making scarlet fever distinct from classic streptococcal pharyngitis 4
- The median age of presentation is 3.8 years, with most cases occurring between ages 5-15 years 2, 4
Key Distinguishing Features
What Scarlet Fever Typically LACKS (helping differentiate from viral illness):
These viral features, when present, strongly suggest an alternative diagnosis.
Critical Diagnostic Pitfall
The classic Centor score performs poorly in scarlet fever—86% of cases score ≤2 points, which would traditionally argue against streptococcal infection 4. The presence of the characteristic rash must override clinical prediction rules, regardless of patient age 4.
Atypical Presentations to Recognize
- Rash distribution can be atypical, occasionally involving only the dorsum of hands and feet to the level of wrists and ankles 8
- Adults can develop scarlet fever, though less commonly, with similar symptomatology including fever (96%), sore throat (89%), rash (87%), and strawberry tongue (67%) 7
- Absence of fever does not exclude the diagnosis, though it strongly suggests viral etiology—bacterial pharyngitis without fever is uncommon but possible 2
Immediate Action Required
Laboratory confirmation with rapid antigen detection test (RADT) or throat culture is essential before initiating antibiotics, as clinical scoring systems predict positive results only ≤80% of the time 2, 3. However, when the characteristic rash is present alongside pharyngitis and fever, the diagnosis is highly likely and treatment should not be delayed pending culture results 1, 2.
Early antibiotic treatment within 24 hours renders the patient non-contagious and prevents serious complications including acute rheumatic fever, glomerulonephritis, and endocarditis 1, 3, 5.