Recrudescence of Scarlet Fever and Its Implications for Dental Professionals.

A significant increase in the incidence of scarlet fever, mainly in Europe, has been noted during the COVID-19 postpandemic period. Scarlet fever is caused by a pyrogenic exotoxin-producing streptococcus-Streptococcus pyogenes-responsible for more than 500,000 deaths annually worldwide. Superantigens (SAgs) secreted by this Group A streptococcus (GAS) usually overstimulate the human immune system, causing an amplified hypersensitivity reaction leading to initial symptoms such as sore throat, high fever, and a sandpaper-like skin rash. There could be concurrent oral manifestations known as "strawberry tongue" or "raspberry tongue," which may be first noted by oral health professionals. The early diagnosis and treatment of this disease is critical to obviate the development of local and systemic sequelae such as acute rheumatic fever, endocarditis, and glomerulonephritis. Antibiotics should be prescribed early to mitigate its duration, sequelae, and community spread. Dental practitioners should be aware of the early symptoms of scarlet fever for infection detection, emergency patient management, and appropriate referral. This concise review outlines the prevalence, pathogenicity, oral and systemic manifestations, as well as the dental implications of scarlet fever.

Retrospective study on the effectiveness and safety of the shortened 5- to 7-day antibiotic regimen for acute streptococcal pharyngotonsillitis compared to the classic 10-day regimen.

INTRODUCTION: Antibiotherapy regimens for management of acute streptococcal pharyngitis traditionally last 10 days, but the development of resistance to different antimicrobials has motivated the exploration of shorter courses. MATERIAL AND METHODS: We selected patients given a diagnosis of streptococcal pharyngitis in 2 paediatric caseloads of 1 primary care centre between June 2016 and April 2020. We compared outcomes in patients treated with 8- to 10-day courses versus 5- to 7-day courses. RESULTS: The analysis included 350 care episodes (252 patients). Sixty-four percent were managed with 8- to 10-day courses of antibiotherapy (group 1) and 36% with 5- to 7-day courses (group 2). There were no significant differences in the incidence of streptococcal pharyngitis or scarlet fever in the 3 months that followed (OR, 0.98; 95% confidence interval [CI], 0.46-2.03), with similar percentages in both groups (9.8% vs 9.5%). Overall, without differentiating based on the type of infection (streptococcal pharyngitis, scarlet fever or other streptococcal infections), we found similar outcomes (OR, 0.81; 95% CI, 0.41-1.59): 13.4% in group 1 and 11.1% in group 2. We also found no differences in the frequency of adverse events documented in the health records (OR, 0.29; 95% CI, 0.04-2.44): 2.7% in group 1 and 0.8% in group 2. CONCLUSIONS: In our experience, a shorter antibiotic course (5-7 days) is not less effective or more unsafe for management of acute streptococcal pharyngitis than the traditional 10-day course.

Clinical management and impact of scarlet fever in the modern era: findings from a cross-sectional study of cases in London, 2018-2019.

OBJECTIVES: In response to increasing incidence of scarlet fever and wider outbreaks of group A streptococcal infections in London, we aimed to characterise the epidemiology, symptoms, management and consequences of scarlet fever, and to identify factors associated with delayed diagnosis. DESIGN AND SETTING: Cross-sectional community-based study of children with scarlet fever notified to London's three Health Protection Teams, 2018-2019. PARTICIPANTS: From 2575 directly invited notified cases plus invitations via parental networks at 410 schools/nurseries with notified outbreaks of confirmed/probable scarlet fever, we received 477 responses (19% of those directly invited), of which 412 met the case definition. Median age was 4 years (range <1 to 16), 48% were female, and 70% were of white ethnicity. OUTCOME MEASURES: Preplanned measures included quantitative description of case demographics, symptoms, care-seeking, and clinical, social, and economic impact on cases and households. After survey completion, secondary analyses of factors associated with delayed diagnosis (by logistic regression) and consequences of delayed diagnosis (by Cox's regression), and qualitative analysis of free text comments were added. RESULTS: Rash was reported for 89% of cases, but followed onset of other symptoms for 71%, with a median 1-day delay. Pattern of onset varied with age: sore throat was more common at onset among children 5 years and older (OR3.1, 95% CI 1.9 to 5.0). At first consultation, for 28%, scarlet fever was not considered: in these cases, symptoms were frequently attributed to viral infection (60%, 64/106). Delay in diagnosis beyond first consultation occurred more frequently among children aged 5+ who presented with sore throat (OR 2.8 vs 5+without sore throat; 95% CI 1.3 to 5.8). Cases with delayed diagnosis took, on average, 1 day longer to return to baseline activities. CONCLUSIONS: Scarlet fever may be initially overlooked, especially among older children presenting with sore throat. Raising awareness among carers and practitioners may aid identification and timely treatment.

Miliaria Scarlatinosa, A Peculiar and Rare Form of Scarlet Fever - A Case Report.

Scarlet fever typically presents with distinctive erythematous papular rash following pharyngitis. Atypical forms may develop, making the diagnosis difficult. We present the case of a girl with fever, and unusual vesicular skin eruption (miliaria scarlatinosa) preceded by a skin infection, without mucosal changes. Leukocyte count, C-reactive protein, and antistreptolysin O-titer were elevated. Bacteriological swabs of the skin injury revealed Streptococcus pyogenes. Histopathology was compatible with scarlet fever exanthema. Intramuscular penicillin and topical wound care induced complete remission. It is of great importance to be aware of uncommon clinical presentations of scarlet fever in order to establish a timely diagnosis and prevent potential complications.

Exposure to air pollution and scarlet fever resurgence in China: a six-year surveillance study.

Scarlet fever has resurged in China starting in 2011, and the environment is one of the potential reasons. Nationwide data on 655,039 scarlet fever cases and six air pollutants were retrieved. Exposure risks were evaluated by multivariate distributed lag nonlinear models and a meta-regression model. We show that the average incidence in 2011-2018 was twice that in 2004-2010 [RR = 2.30 (4.40 vs. 1.91), 95% CI: 2.29-2.31; p < 0.001] and generally lower in the summer and winter holiday (p = 0.005). A low to moderate correlation was seen between scarlet fever and monthly NO2 (r = 0.21) and O3 (r = 0.11). A 10 µg/m3 increase of NO2 and O3 was significantly associated with scarlet fever, with a cumulative RR of 1.06 (95% CI: 1.02-1.10) and 1.04 (95% CI: 1.01-1.07), respectively, at a lag of 0 to 15 months. In conclusion, long-term exposure to ambient NO2 and O3 may be associated with an increased risk of scarlet fever incidence, but direct causality is not established.

Increase of emm1 isolates among group A Streptococcus strains causing scarlet fever in Shanghai, China.

OBJECTIVE: Scarlet fever epidemics caused by group A Streptococcus (GAS) have been ongoing in China since 2011. However, limited data are available on the dynamic molecular characterizations of the epidemic strains. METHOD: Epidemiological data of scarlet fever in Shanghai were obtained from the National Notifiable Infectious Disease Surveillance System. Throat swabs of patients with scarlet fever and asymptomatic school-age children were cultured. Illumina sequencing was performed on 39emm1 isolates. RESULTS: The annual incidence of scarlet fever was 7.5-19.4/100,000 persons in Shanghai during 2011-2015, with an average GAS carriage rate being 7.6% in school-age children. The proportion ofemm1 GAS strains increased from 3.8% in 2011 to 48.6% in 2014; they harbored a superantigen profile similar to emm12 isolates, except for the speA gene. Two predominant clones, SH001-emm12, and SH002-emm1, circulated in 66.9% of scarlet fever cases and 44.8% of carriers. Genomic analysis showed emm1 isolates throughout China constituted distinct clades, enriched by the presence of mobile genetic elements carrying the multidrug-resistant determinants ermB and tetM and virulence genes speA, speC, and spd1. CONCLUSION: A significant increase in the proportion ofemm1 strains occurred in the GAS population, causing scarlet fever in China. Ongoing surveillance is warranted to monitor the dynamic changes of GAS clones.

Scarlet fever - a diagnostic challenge for dentists and physicians: A report of 2 cases with diverse symptoms.

Scarlet fever is an infectious disease caused by group A streptococcal bacteria, transmitted mainly through direct contact with the saliva and nasal fluids of infected people. It may also arise from streptococcal wound infections or burns. The disease most commonly affects children aged 5-15 years and manifests as a sore throat, fever and a sandpaper-like, papular skin rash. Due to the evident involvement of the oral structures, the awareness of the symptoms of scarlet fever is essential for dentists in order to avoid the spread of this highly contagious disease in crowded places, such as kindergartens and schools. As no vaccine is available to prevent scarlet fever, the early diagnosis and treatment of this condition are important in reducing the risk of developing local and systemic complications, which include acute rheumatic fever, glomerulonephritis, bacteremia, pneumonia, endocarditis, and meningitis. In this report, 2 cases of scarlet fever are described in unrelated children with diverse symptoms, and diagnostic and therapeutic strategies are discussed.

Staphylococcal scarlet fever associated with staphylococcal enterotoxin M in an elderly patient.

Staphylococcal scarlet fever (SSF) is characterized by an exanthem without enanthem, bullae, or exfoliation, and is known to be related to Staphylococcus aureus toxins, especially superantigens. It has been reported in children and young adults. Herein, we report the first case of an elderly patient with SSF caused by staphylococcal enterotoxin M (SEM), associated with otitis externa. The patient presented with maculopapular rashes on both arms, thighs, and abdomen and with erythroderma on the face, ears, neck, chest, and back, all of which was followed by desquamation on the face, ears, and trunk. A culture of ear discharge grew methicillin susceptible S. aureus that was only positive for SEM among the superantigens tested.

Detection of Epidemic Scarlet Fever Group A Streptococcus in Australia.

Sentinel hospital surveillance was instituted in Australia to detect the presence of pandemic group A Streptococcus strains causing scarlet fever. Genomic and phylogenetic analyses indicated the presence of an Australian GAS emm12 scarlet fever isolate related to United Kingdom outbreak strains. National surveillance to monitor this pandemic is recommended.

You're the Flight Surgeon.

Nolan CF. You're the flight surgeon: scarlet fever. Aerosp Med Hum Perform. 2019; 90(2):139-143.

Scarlet fever associated with hepatitis in pediatrics. A case report. / Scarlet fever associated with hepatitis in pediatrics. A case report.

INTRODUCTION: Scarlet fever is a common illness in pediatrics caused by group A beta-hemolytic strep tococcus (GABHS), which usually occurs after an episode of pharyngitis, and has an overall excellent prognosis. Hepatitis secondary to scarlet fever is a rare complication described in adults and even less frequently in children. Our objective was to describe a case of hepatitis secondary to scarlet fever in a pediatric patient. CLINICAL CASE: A 12-year-old male with scarlet fever presented with a 4-day history of jaundice, dark urine, and decreased appetite. Laboratory tests revealed elevated liver enzy mes and total and direct bilirubin levels, and negative studies for hepatitis A, B and C, Epstein Barr virus, parvovirus B19, adenovirus, cytomegalovirus, human herpes virus-6, and herpes simplex virus 1 and 2. Abdominal ultrasound examination was normal. DISCUSSION: The pathogenesis of scarlet fever associated hepatitis remains unclear. Streptococcal pyrogenic exotoxin mediated cellular injury via cytokine production has been proposed as a possible mechanism of hepatotoxicity in GABHS infections. CONCLUSION: Hepatitis secondary to scarlet fever remains a rare but benign entity, with complete recovery expected over weeks to months.

[Study on the super-antigen genes of group A Streptococcus pyogenes strains isolated from patients with scarlet fever and pharyngeal infection, in Beijing, 2015-2017].

Objective: To analyze the characteristics of super-antigen (SAg) of group A Streptococcus pyogenes (GAS), isolated from patients with scarlet fever or pharyngeal infections in Beijing between 2015-2017. Methods: Throat swab specimens from patients with scarlet fever or pharyngeal infections were collected and tested for GAS. Eleven currently known SAg genes including SpeA, speC, speG, speH, speI, speJ, speK, speL, speM, smeZ and ssa were tested by real-time PCR while M protein genes (emm genes) were amplified and sequenced by PCR. Results: A total of 377 GAS were isolated from 6 801 throat swab specimens, with the positive rate as 5.5%. There were obvious changes noticed among speC, speG, speH and speK in three years. A total of 45 SAg genes profiles were observed, according to the SAgs inclusion. There were significant differences appeared in the frequencies among two of the highest SAg genes profiles between emm1 and emm12 strains (χ(2)=38.196, P<0.001; χ(2)=72.310, P<0.001). There also appeared significant differences in the frequencies of speA, speH, speI and speJ between emm1 and emm12 strains (χ(2)=146.154, P<0.001; χ(2)=52.31, P<0.001; χ(2)=58.43, P<0.001; χ(2)=144.70, P<0.001). Conclusions: Obvious changes were noticed among SAg genes including speC, speG, speH and speK from patients with scarlet fever or pharyngeal infections in Beijing between 2015-2017. SAg genes including speA, speH, speI and speJ appeared to be associated with the emm 1 and emm 12 strains. More kinds of SAg genes profiles were isolated form GAS but with no significant differences seen in the main SAg genes profiles, during the epidemic period.

Scarlet fever associated with hepatitis in pediatrics: a case report / Hepatitis asociada a escarlatina en pediatría: reporte de caso

INTRODUCCIÓN: La escarlatina es una enfermedad común en Pediatría, causada por Estreptococo beta hemolítico grupo A (SBHGA), la cual generalmente se presenta después de un episodio de faringitis, y con excelente pronóstico general. La hepatitis secundaria a escarlatina es una complicación, descrita muy rara vez en niños. Nuestro objetivo fue reportar la ocurrencia de hepatitis secundaria a escarlati na en un paciente pediátrico. CASO CLÍNICO: Varón de 12 años cursando escarlatina, quien se presentó con una historia de 4 días de ictericia, coluria y disminución del apetito. Los exámenes de laboratorio revelaron elevación de las transaminasas y de los niveles de bilirrubina total y directa, y estudios vira les negativos para Hepatitis A, B y C, Virus de Epstein Barr, Parvovirus B19, Citomegalovirus, Virus Herpes 6 y Herpes simplex 1 y 2. Ecografía abdominal fue normal. DISCUSIÓN: La hepatitis es una complicación inhabitual de la escarlatina, cuya patogénesis aún no está clara. La producción de citoquinas a través del daño celular mediado por la exotoxina pirógena estreptocócica, se ha propuesto como un posible mecanismo de hepatotoxicidad en infecciones por SBHGA. CONCLUSIÓN: La hepati tis asociada a escarlatina continúa siendo una entidad rara, pero de curso benigno, con recuperación plena en semanas a meses.

INTRODUCTION: Scarlet fever is a common illness in pediatrics caused by group A beta-hemolytic streptococcus (GABHS), which usually occurs after an episode of pharyngitis, and has an overall excellent prognosis. Hepatitis secondary to scarlet fever is a rare complication described in adults and even less frequently in children. Our objective was to describe a case of hepatitis secondary to scarlet fever in a pediatric patient. CLINICAL CASE: A 12-year-old male with scarlet fever presented with a 4-day history of jaundice, dark urine, and decreased appetite. Laboratory tests revealed elevated liver enzy mes and total and direct bilirubin levels, and negative studies for hepatitis A, B and C, Epstein Barr virus, parvovirus B19, adenovirus, cytomegalovirus, human herpes virus-6, and herpes simplex virus 1 and 2. Abdominal ultrasound examination was normal. DISCUSSION: The pathogenesis of scarlet fever associated hepatitis remains unclear. Streptococcal pyrogenic exotoxin mediated cellular injury via cytokine production has been proposed as a possible mechanism of hepatotoxicity in GABHS infections. CONCLUSION: Hepatitis secondary to scarlet fever remains a rare but benign entity, with complete recovery expected over weeks to months.

Unusual case of suspected recurrent scarlet fever in a UK serviceman.

The UK prevalence of scarlet fever, a Group A streptococcal infection, is increasing. We present an unusual case of suspected recurrent scarlet fever in a member of the UK Armed Forces. Treatments, occupational implication and public health measures to mitigate the risk of disease spread.

Far East Scarlet-like Fever Masquerading as Adult-onset Kawasaki Disease.

A previously healthy 31-year-old man was referred to us with refractory septic shock accompanied by bilateral conjunctival congestion and erythema of his right lower limb. Nine days after admission, he had bilateral desquamation of the fingertips, and his presentation satisfied the criteria for Kawasaki disease. A serological examination was positive for Yersinia pseudotuberculosis, and he was diagnosed with Far East scarlet-like fever (FESLF). Interestingly, his 11-month-old baby boy had similar symptoms around the same time, indicating the intrafamilial transmission of the pathogen. We should consider FESLF when we encounter a familial occurrence of systemic manifestations of Kawasaki disease.

'Outbreak Gold Standard' selection to provide optimized threshold for infectious diseases early-alert based on China Infectious Disease Automated-alert and Response System.

The China Infectious Disease Automated-alert and Response System (CIDARS) was successfully implemented and became operational nationwide in 2008. The CIDARS plays an important role in and has been integrated into the routine outbreak monitoring efforts of the Center for Disease Control (CDC) at all levels in China. In the CIDARS, thresholds are determined using the "Mean+2SD? in the early stage which have limitations. This study compared the performance of optimized thresholds defined using the "Mean +2SD? method to the performance of 5 novel algorithms to select optimal "Outbreak Gold Standard (OGS)? and corresponding thresholds for outbreak detection. Data for infectious disease were organized by calendar week and year. The "Mean+2SD?, C1, C2, moving average (MA), seasonal model (SM), and cumulative sum (CUSUM) algorithms were applied. Outbreak signals for the predicted value (Px) were calculated using a percentile-based moving window. When the outbreak signals generated by an algorithm were in line with a Px generated outbreak signal for each week, this Px was then defined as the optimized threshold for that algorithm. In this study, six infectious diseases were selected and classified into TYPE A (chickenpox and mumps), TYPE B (influenza and rubella) and TYPE C [hand foot and mouth disease (HFMD) and scarlet fever]. Optimized thresholds for chickenpox (P55), mumps (P50), influenza (P40, P55, and P75), rubella (P45 and P75), HFMD (P65 and P70), and scarlet fever (P75 and P80) were identified. The C1, C2, CUSUM, SM, and MA algorithms were appropriate for TYPE A. All 6 algorithms were appropriate for TYPE B. C1 and CUSUM algorithms were appropriate for TYPE C. It is critical to incorporate more flexible algorithms as OGS into the CIDRAS and to identify the proper OGS and corresponding recommended optimized threshold by different infectious disease types.