A 12-year-old boy is brought to the office with fever, chills, and a rash that appeared this morning. Two days earlier, the child started complaining of a sore throat. His temperature is 38.3 C (101 F). Examination shows a diffuse erythematous rash on his chest and abdomen that blanches with pressure, along with numerous 1- to 2-mm papules. The throat is erythematous with gray-white tonsillar exudates and the tongue is bright red. Which of the following complications is most likely to develop in this patient?

Question

A 12-year-old boy is brought to the office with fever, chills, and a rash that appeared this morning.  Two days earlier, the child started complaining of a sore throat.  His temperature is 38.3 C (101 F).  Examination shows a diffuse erythematous rash on his chest and abdomen that blanches with pressure, along with numerous 1- to 2-mm papules.  The throat is erythematous with gray-white tonsillar exudates and the tongue is bright red.  Which of the following complications is most likely to develop in this patient?

Quizplus · Accepted Answer

This patient most likely has scarlet fever, which is caused by strains of Group A streptococcus that produce pyrogenic exotoxins. Scarlet fever is most often associated with streptococcal pharyngitis, which begins acutely after an incubation period of 1-5 days. Initial symptoms include fever, malaise, abdominal pain, and sore throat. The pharynx is typically erythematous, swollen, and possibly covered with gray-white exudates. In addition, the tongue can have inflamed red papillae with an appearance similar to that of a red strawberry. After 1-2 days, a rash appears on the neck, armpits, and groin that subsequently generalizes to the rest of the body. The rash begins as scarlet spots or blotches, giving a boiled lobster appearance. As the rash progresses and becomes more widespread, it begins to resemble a sunburn with goose pimples ("sandpaper-like" rash). The cheeks commonly appear flushed, giving the area around the mouth a pale appearance in comparison (circumoral pallor). Toward the end of the first week, desquamation begins and is most pronounced in the armpits, groin, and tips of the fingers and toes. As with any streptococcal upper respiratory infection, scarlet fever can predispose to acute rheumatic fever and glomerulonephritis. Treatment with penicillin V can prevent the development of rheumatic fever, although its role in preventing glomerulonephritis is uncertain. (Choice A) Aplastic anemia can complicate parvovirus B19 infection in patients with sickle cell anemia or immunocompromisation. (Choice B) Coronary artery aneurysm is the most dreaded complication of Kawasaki disease, which can present with fever, strawberry tongue, and a rash. However, tonsillar exudates are more typical of bacterial disease, and this patient lacks other manifestations of Kawasaki disease (eg, bilateral conjunctival injection). (Choice C) Measles virus infection is associated with a rash that classically starts on the face and Koplik spots (small whitish/blue lesions on buccal mucosa). Neurological complications can include encephalitis (acutely), acute disseminated encephalomyelitis (during recovery), and subacute sclerosing panencephalitis (years later). (Choice D) Orchitis is one of the most common complications of mumps. Mumps characteristically presents with fever, malaise, headaches, and myalgias followed by the development of parotitis within 48 hours. Educational objective: Scarlet fever is characterized by fever, pharyngitis, sandpaper-like rash, circumoral pallor, and a strawberry tongue. It is caused by strains of Group A streptococcus that produce pyrogenic exotoxins. Scarlet fever can predispose to acute rheumatic fever and glomerulonephritis.

A 12-Year-Old Boy Is Brought to the Office with Fever