This document presents a case history for a 6-year-old boy, S.K., who presented with a rash and fever. Over 4 days, the rash spread and he developed swelling of the hands, vomiting, diarrhea, and worsening fever. Differential diagnoses included viral exanthems, scarlet fever, toxin-mediated rash, and Kawasaki disease. On examination, he had a maculopapular rash, swollen throat and tonsils, and swelling of the hands and lower limbs. Investigations and management for potential scarlet fever were discussed.

2. CASE HISTORY
• S.K. , 6 yr old boy
PC
 Rash + Fever

3. HPC
1st day: rash started in peri-oral area 4/7 days ago;
-Itchy
-Blanching
-No apparent triggers reported by parents
-During the following 24 hours rash spread to the cheeks , UL and LL , chest , back
and abdomen.
2nd day: associated fever and swelling on hands with rash. GP prescribed
-Calamine lotion: pruritus
- Piriton: chlorphenamine.
3rd day: symptoms' worsened, + Vomiting +Diarrhoea.
- Given paracetamol , PO and penicillin V, PO

4. HPC
4th day: continuing vomiting +Diarrhoea.
- The swelling in the hands extended progressively, with added
discomfort and pain on walking and mobility of 4 limbs.
-Fever did not improve.
TRIAGE VITALS
-He was brought in to the hospital for a second time:
Temp: 38 C
BP: 130/90
RR: 28
O2: 100%

5. HPC
Any thoughts??? Any questions ??
..
No coryza symptoms
No dysuria
Immunisation up to date
No foreign travel / visitors
No family member with same symptoms

6. PMH
Pregnancy : normal , no drugs taken.
Perinatal: normal, no complications.
Delivery: no complications.
Postnatal: no complications.
Infancy: repetitive upper respiratory tract infections.
Development: Normal development. Walked when he was able to stand with help at 1 yr
, able to walk at 1 , 5/12yrs
Immunizations: up to date.
Surgical Hx: Orchidopexia , due to undescended testis at 1 yr
Medical Hx: nothing reported by parents
Med: nil reg
Allergies: none known.

7. FH
-2 Older sisters healthy.
-No one in the family with similar symptoms.
-Father: cardiac problems and high cholesterol on father family line.
-Mother: (-)
SH
-He currently attends school on yr 1
-No problems with school, no problems socialising “he’s actually a very popular
kid”
-No problems at home reported.
-No recent travel
-No pets

8. S/R
-General: looking poorly for last 4 days, feeding ok and
drinking ok , despite vomiting.
-ENT: dry cough before the episode of rash + fever , swollen
tonsils, difficulties with swallowing.
-GI: diarrhoea
-RS: no asthma , no SOB, no palpitations
-CVS: (-)
-GUS: urine colour changes
-NS: (-)
-MSS: pain in hand bilaterally ,
-SKIN: raised skin temperature + swelling, itchy maculopapular
rash.

9. O/E
-General: alert , responsive cooperative child to examination
38 C
-RS: (-)
-CVS: (-) no cyanosis, no clubbing, no SOB, no murmurs.
-ENT: inflamed red throat, red swollen tongue, no palate
erythema, ears: L=clear R= waspy , tonsils grade 2-3
-Eyes: no conjunctivitis
-NS: (-)
-MSS: bilateral palmar and plantar erythema, bilateral swelling
of both UL & LL, non pitting oedema on both LL and
UL, pulses present in both UL and LL.
-SKIN: generalised warm skin temperature +
swelling, maculopapular rash on the back , patchy over the
thighs.

10. Differentials
????
- 5 viral exanthems
-Scarlet fever
-Toxin mediated rash
- Kawasaki disease

11. Diagnosis
Key points to reach diagnosis: fever + rash
-Decide which type of rash is:
macular, maculopapular, vesicular purpuric.
-Determine if the child is ill.
-Beware of diagnosis Measles or Rubella without serological
confirmation.
-If the rash is petechial or purpuric child unwell ,treat with
penicillin IM and admit for investigation.

12. Investigations
????
-Bloods: FBC, , CRP, ESR, U&E’s, LFT, Coag profile
-Dip stick Urine
-Throat swab
-ASO antistrepto-lysin titres
-ECG
- C3,C4

13. Management
- Fluids
- Antibiotics
- Antipiretic/ analgesia
- Vital signs monitoring

14. Scarlet Fever
- Rash that may occur with Streptoccocal pharyngitis.
- Caused by group A haemolytic streptoccoci.
- Treated with Antibiotic.

15. Scarlet Fever
CLINICAL FEATURES
- 2-4 incubation period
- Headache and tonsillitis appear after
- Rash develops within 2 hours
- Spreads rapidly over trunk and neck
- With increased density in the neck, axillae and groins.

16. Scarlet Fever
.
CLINICAL FEATURES
- A fine punctuate erythematous appearance
- A “sand papery” feel.
- And blanching on pressure.
- Tongue white first then “red strawberry”
- Rash lasts about 6 days followed by peeling

17. Scarlet Fever
.
INVESTIGATIONS
- Throat swab mat show group A streptococcus
- Antistreptolysin ( ASO ) titre is high.

18. Scarlet Fever
.
MANAGEMENT
- 10- day course of penicillin V or erythromycin
- Isolation: children should be isolated until 24th after the start of antiibiotics
- Antibiotic prevents other children from being infected and reduce lenght of
illness.
- Should be started within 9 days of acute illness.
- Follow updated hospital guidelines if at all any.

19. Scarlet Fever
.
COMPLICATIONS
Peritonsilar abscess
Retropharyngeal abscess
Acute Glomerulonephritis (2 weeks)
Rheumatic fever
Pneumonia
Meningitis / Brain absses (incidence)
Sepsis

20. Scarlet Fever

21. References
 Rudolf M, Lee T, Levene M. Paediatrics and Child Health. Wiley Blackwell, 2001; 3rd ed.
 Lissauer T, Clayden G. Illustrated textbook of Paediatrics. UK: Mosby Elsevier, 2007; 3rd ed.
 Tasker R, McClure R, Acerini C. Oxford handbook of Paediatrics. Oxford: Oxford University
press, 2008.

22. The end