A 7-year-old boy presents with his father to the pediatrician with a 4-day history of sore throat, nausea, and fever. He has otherwise been well, does not have chronic medical issues, and is up to date on his immunizations. His younger sister was kept home from daycare last week for strep throat which was confirmed by throat swab. Physical examination is significant for a temperature of 100.8°F (32.8°C), exudative tonsillopharyngitis, and an erythematous, finely papular rash over most of the body.
Which of the following additional physical examination findings is most likely to be present at this time?
C) Red and bumpy tongue
This describes a “strawberry tongue,” which is a feature of scarlet fever. Scarlet fever occurs due to infection with erythrogenic toxin-producing Group A Streptococcus and classically presents with a fine, “sandpaper rash.” Circumoral pallor may also be present. Of note, Kawasaki disease can cause similar symptoms and should always be considered in this differential.
Answer choice A: Additional macular rash with asymmetric, curved borders, is incorrect. This describes erythema marginatum, which is a sequelae of rheumatic fever. Rheumatic fever is defined by the Jones criteria and typically appears 2-4 weeks after infection with Group A Streptococcus. These patients require long-term prophylactic antibiotics to prevent further complications.
Answer choice B: Cardiac murmur, is incorrect. This is a component of rheumatic fever.
Answer choice D: Subcutaneous nodules, is incorrect. This is a component of rheumatic fever.
Answer choice E: Twisting movements of the extremities, is incorrect. This describes Sydenham chorea, which is a component of rheumatic fever.
Key Learning Point
In contrast to rheumatic fever, which arises 2-4 weeks after GAS infection, scarlet fever co-occurs with primary infectious symptoms and is characterized by a sandpaper rash, strawberry tongue, and circumoral pallor.
