This disease presents with a sore throat after which fever sets in. There is redness and swelling of the tongue with spots called ‘Strawberry tongue’. Small red spots may also be present inside the oral cavity, particularly on the soft palate called Forchheimer spots.

Scarlet fever is classically manifested by a punctuate erythematous rash that is most prominent over the trunk and inner aspects of the arms and legs [8]. The rash is a characteristic feature of scarlet fever. It presents within 12-72 hours after the fever sets in and appears as a fine, rough, red coloured rash that begins in the trunk and armpits and then progresses over to the face and the rest of the body. It typically blanches under pressure and when present on the face, it presents with erythema of the face leaving a pale circular area around the mouth, which is called circumoral pallor. This rash is characteristically prominent on skin folds, called Pastia lines.

• Cervical Lymphadenopathy

  Local spread: Cervical lymphadenopathy. Sinusitis. Mastoiditis. Peritonsillar abscess. Distant spread: Pneumonia. Meningitis. Osteomyelitis. Septic arthritis. Brain abscess. Intracranial venous sinus thrombosis. Septicaemia. [patient.info]

  Go to https://www.patreon.com/medicosis Scarlet fever is caused by gram stain-positive group A beta hemolytic streptococci (GABS), its symptoms include: fever, pharyngitis, red strawberry tongue, cervical lymphadenopathy, sandpaper-like rash over the [youtube.com]

  All episodes were confirmed microbiologically by means of a RST (84%) or culture (16%), and we collected data for the following variables: episode number, fever, cold symptoms, cough, cervical lymphadenopathy, tonsillar hyperaemia and/or exudate, petechiae [analesdepediatria.org]

  Headache Fever Chills Malaise Abdominal pain Nausea Vomiting Swollen and tender lymph nodes on the sides of the neck (cervical lymphadenopathy) Approximately one to four days after the onset of illness, a characteristic skin rash will appear with the [emedicinehealth.com]

• Fever

  Scarlet fever has no vaccine available. [symptoma.com]

  Clinical Knowledge Summaries: Scarlet fever Scenario: Management. NICE. October 2015. Available from: https://cks.nice.org.uk/scarlet-fever#! [doi.org]

  […] or body aches Nausea, vomiting, or abdominal pain Swollen glands Scarlet Fever: What to Expect Illness usually begins with a fever and sore throat. [web.archive.org]

  This is crucial to prevent rheumatic fever, a serious complication of strep throat and scarlet fever. With proper antibiotic treatment, the symptoms of scarlet fever should get better quickly. [nlm.nih.gov]

• Chills

  It may be accompanied by chills, vomiting, abdominal pain and malaise. The streptococcal bacteria produces a toxin that causes a rash that appears one to two days after the onset of illness. [mountsinai.org]

  […] recurrens Recurrent aphthous ulcer Stomatitis herpetiformis rash A38.9 Disease, diseased - see also Syndrome Fothergill's scarlatina anginosa A38.9 Febris, febrile - see also Fever rubra A38.9 Fever (inanition) (of unknown origin) (persistent) (with chills [icd10data.com]

  Before the rash develops, scarlet fever can cause a variety of symptoms in your child including: fever sore throat chills headache vomiting stomach ache coated white tongue The rash begins about one to two days after the initial infection. [childrenshospital.org]

  Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Your health care provider may [nlm.nih.gov]

• Streptococcal Pharyngitis

  After a young woman had scarlet fever associated with group C beta-hemolytic streptococcal pharyngitis, we reviewed all cases of pharyngitis treated at a student health clinic during that semester. [ncbi.nlm.nih.gov]

  Therefore, scarlet fever can be "caught" from someone who has only streptococcal pharyngitis. Scarlet fever is most common among children, although any age is susceptible. [science.jrank.org]

  Management of group A beta-hemolytic streptococcal pharyngitis. [doi.org]

  Streptococcal pharyngitis Other names Streptococcal tonsillitis, streptococcal sore throat, strep A culture positive case of streptococcal pharyngitis with typical tonsillar exudate in a 16-year-old. [en.wikipedia.org]

  Clinical algorithms are available to assist with the diagnosis of acute streptococcal pharyngitis. [pharmaceutical-journal.com]

• Malaise

  It may be accompanied by chills, vomiting, abdominal pain and malaise. The streptococcal bacteria produces a toxin that causes a rash that appears one to two days after the onset of illness. [mountsinai.org]

  Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Your health care provider may [nlm.nih.gov]

  Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Exams and Tests Your health care [ufhealth.org]

• Lymphadenopathy

  Local spread: Cervical lymphadenopathy. Sinusitis. Mastoiditis. Peritonsillar abscess. Distant spread: Pneumonia. Meningitis. Osteomyelitis. Septic arthritis. Brain abscess. Intracranial venous sinus thrombosis. Septicaemia. [patient.info]

  Go to https://www.patreon.com/medicosis Scarlet fever is caused by gram stain-positive group A beta hemolytic streptococci (GABS), its symptoms include: fever, pharyngitis, red strawberry tongue, cervical lymphadenopathy, sandpaper-like rash over the [youtube.com]

  All episodes were confirmed microbiologically by means of a RST (84%) or culture (16%), and we collected data for the following variables: episode number, fever, cold symptoms, cough, cervical lymphadenopathy, tonsillar hyperaemia and/or exudate, petechiae [analesdepediatria.org]

  The pharyngotonsillar GAS (PAS) infection in childhood is described as an exudative tonsillitis with acute start, febrile, occasionally with feeling seriously sick and cervical lymphadenopathy, usually with no coryza symptoms but which particularly affects [elsevier.es]

• Sore Throat

  Since either viruses or other bacteria can also cause sore throats, it's important to ask the doctor about getting a strep test (a simple swab of the throat) if your child complains of having a sore throat. [web.archive.org]

  Doctors Can Test for and Treat Scarlet Fever Many viruses and bacteria can cause an illness that includes a red rash and sore throat. Ask the doctor about getting a strep test if your child has a red rash and a sore throat. [cdc.gov]

  To diagnose the cause of your child’s rash or sore throat, your doctor will examine your child and might swab the back of the throat with a cotton swab. The swab will be then used for a throat culture to see if there is a group A strep infection. [deputyprimeminister.gov.mt]

  Prevention The best prevention is thorough hand washing, especially by those who have a sore throat or other symptoms of strep infection. [drugs.com]

  Method 1 Recognizing Strep Throat 1 Watch for a sore throat. Not all sore throats are caused by strep, but a sore throat is the most common symptom of strep. Be mindful of throat pain and difficulty or pain when swallowing. [wikihow.com]

• Cough

  Cover your mouth and nose with a tissue when you cough or sneeze, or cough or sneeze into your upper sleeve or elbow, not your hands, if you don’t have a tissue. Wash your hands often with soap and water for at least 20 seconds. [oakgov.com]

  You can prevent the spread of scarlet fever and ‘strep throat’ by following this advice: Cover your mouth and nose with a tissue when you cough or sneeze. Throw tissues in the bin after you use them. [healthywa.wa.gov.au]

  Antibiotics are also known as antibacterials, and they are used to treat infections caused by bacteria, such as scarlet fever or whooping cough. Antibiotics target only bacteria. [web.archive.org]

  This is especially important after coughing or sneezing and before preparing foods or eating. [cdc.gov]

• Pharyngitis

  After a young woman had scarlet fever associated with group C beta-hemolytic streptococcal pharyngitis, we reviewed all cases of pharyngitis treated at a student health clinic during that semester. [ncbi.nlm.nih.gov]

  Management of group A beta-hemolytic streptococcal pharyngitis. [doi.org]

  Majority related to strep pharyngitis, with 1 in 10 developing scarlet fever (Figures 34-1, 34-2, and 34-4). Prevalent in late fall to early spring. [accessmedicine.mhmedical.com]

• Vomiting

  There also may be chills, vomiting, and abdominal pain. The tongue may have a whitish coating and appear swollen. It may also have a "strawberry"-like (red and bumpy) appearance. [web.archive.org]

  It may be accompanied by chills, vomiting, abdominal pain and malaise. The streptococcal bacteria produces a toxin that causes a rash that appears one to two days after the onset of illness. [mountsinai.org]

  There also may be chills, vomiting, or abdominal pain. The tongue may have a whitish coating and appear swollen. It may also have a “strawberry”-like (red and bumpy) appearance. [cdc.gov]

  Before the rash develops, scarlet fever can cause a variety of symptoms in your child including: fever sore throat chills headache vomiting stomach ache coated white tongue The rash begins about one to two days after the initial infection. [childrenshospital.org]

• Nausea

  Some patients will have whitish coating on the tongue or the throat and may have swollen lymph nodes glands, headache, abdominal pain or discomfort resulting in nausea and vomiting, and/or body aches. [medicinenet.com]

  The symptoms of scarlet fever include a sore throat, headache, fever, nausea and vomiting. This is followed by a fine red rash which typically first appears on the chest and stomach, rapidly spreading to other parts of the body. [cumwhinton.cumbria.sch.uk]

  Other symptoms that appear before the rash, especially in children, may include general body aches, headache, stomachache, nausea, vomiting, or listlessness. [northshore.org]

  Symptoms include a sore throat, headache, fever, nausea and vomiting, followed by a fine red rash which typically first appears on the chest and stomach, rapidly spreading to other parts of the body. [antoninfantschool.com]

• Abdominal Pain

  There also may be chills, vomiting, and abdominal pain. The tongue may have a whitish coating and appear swollen. It may also have a "strawberry"-like (red and bumpy) appearance. [web.archive.org]

  It may be accompanied by chills, vomiting, abdominal pain and malaise. The streptococcal bacteria produces a toxin that causes a rash that appears one to two days after the onset of illness. [mountsinai.org]

  There also may be chills, vomiting, or abdominal pain. The tongue may have a whitish coating and appear swollen. It may also have a “strawberry”-like (red and bumpy) appearance. [cdc.gov]

  Other symptoms include: Abdominal pain Bright red color in the creases of the underarm and groin Chills Fever General discomfort (malaise) Headache Muscle aches Sore throat Swollen, red tongue (strawberry tongue) Vomiting Your health care provider may [nlm.nih.gov]

• Strawberry Tongue

  By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with swollen papillae (red strawberry tongue). White strawberry tongue Red strawberry tongue Last revised 11/27/13 © 1996-2013 Neal Chamberlain. All rights reserved. [atsu.edu]

  Strawberry tongue may be observed in patients with scarlet fever, and usually develops within the first 2 to 3 days of illness. A white or yellowish coating usually precedes the classic red tongue with white papillae (Figure 34-3). [accessmedicine.mhmedical.com]

  During the first few days of the infection, a white coating with a bright red tongue (white strawberry tongue) is prevalent. The white membrane falls off leaving a shiny, bright red tongue (red strawberry tongue). [aocd.org]

  The chief diagnostic signs of scarlet fever are the characteristic rash, which spares the palms and soles of the feet, and the presence of a strawberry tongue in children. Strawberry tongue is rarely seen in adults. [healthofchildren.com]

  The tongue is coated and white with red, swollen papillae (white strawberry tongue) until the white coat sloughs off about the fourth day, leaving a red strawberry tongue and red punctate lesions on the palate. [medical-dictionary.thefreedictionary.com]

• Exudative Pharyngitis

  Most commonly, scarlet fever evolves from an exudative pharyngitis. Strawberry tongue may be observed in patients with scarlet fever, and usually develops within the first 2 to 3 days of illness. [accessmedicine.mhmedical.com]

  Background Scarlet fever (known as scarlatina in older literature references) is a syndrome characterized by exudative pharyngitis (see the image below), fever, and bright-red exanthem. [emedicine.com]

• Tonsillar Exudate

  The syndrome occurs in less than 10% of cases of streptococcal tonsillopharyngitis and classically presents with fever, pharyngeal erythema with tonsillar exudates, and a fine, scarlet-colored rash that is most pronounced in the groin, underarm, and elbow [amboss.com]

  There was fever in 89% of the processes (95% CI: 84-94%), with a temperature of >38°C in 73% (95% CI: 65-80%), enlarged lymph nodes in 70% (95% CI: 58-82%), absence of cough in 73% (95% CI: 65-80%), and tonsillar exudate in only 24% (95% CI: 17-31%). [ncbi.nlm.nih.gov]

  All episodes were confirmed microbiologically by means of a RST (84%) or culture (16%), and we collected data for the following variables: episode number, fever, cold symptoms, cough, cervical lymphadenopathy, tonsillar hyperaemia and/or exudate, petechiae [analesdepediatria.org]

  Furthermore, although there was presence of tonsillar swelling in 93% of the episodes (95% CI: 89–97%), tonsillar exudate was just appreciated in 24% (95% CI: 17–31%). [elsevier.es]

  A culture positive case of streptococcal pharyngitis with typical tonsillar exudate in an 8-year-old. [en.wikipedia.org]

• Palatal Petechiae

  Signs Forehead and cheeks appear flushed Circumoral pallor Pharyngitis Tonsil s are hyperemic and edematous, with exudate Throat is inflamed and covered by a membrane Palatal Petechiae may be present Strawberry Tongue Fine Papule s on Tongue surface Tongue [fpnotebook.com]

  This may be accompanied by exudative tonsillopharyngitis, enlarged cervical lymph nodes, small red spots on the palate (petechiae) and a ‘strawberry tongue’. [pharmaceutical-journal.com]

  The throat will be a bright red, but sometimes may just have red spots on the back of the throat or palate, called palatal petechiae. Usually, but not always, a white phlegmy substance (called exudate), can be seen on the tonsils. [ourmed.org]

  Mouth wide open showing the throat Note the petechiae, or small red spots, on the soft palate. [en.wikipedia.org]

• Cheilitis

  "Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment" (PDF). Cutis. 88 (1): 27–32. PMID 21877503. [en.wikipedia.org]

• Arthralgia

  Other minor Jones Criteria are fever, elevated ESR and arthralgia. One of the most serious complications is pancarditis, or inflammation of all three heart tissues. [en.wikipedia.org]

• Flushing

  Peeling Peeling The sandpapery rash does not usually occur on the face, the patient's forehead and cheeks appears red and flushed. In addition to this flushed appearance, there is usually a pale area around their mouth (circumoral pallor). [atsu.edu]

  It spares the face, however, the face may look red/flushed and you might interpret it as a rash. It is not. Also remember, that there is pallor around the face in the presence of the flushed/red face. This pallor is called circumoral pallor. [youtube.com]

  The strain of streptococcus that causes scarlet fever, unlike the one that causes most strep throats, produces an erythrogenic toxin, which causes the skin to flush. [healthofchildren.com]

  Flushed face. The face may appear flushed with a pale ring around the mouth. Strawberry tongue. The tongue generally looks red and bumpy, and it's often covered with a white coating early in the disease. [mayoclinic.org]

  [No authors listed] Abstract Essential facts Scarlet fever is characterised by a rash that usually accompanies a sore throat and flushed cheeks. It is mainly a childhood illness. [ncbi.nlm.nih.gov]

• Skin Rash

  As a result of re-emergence of invasive streptococcal infections, clinicians should be aware of the differential diagnosis of scarlet fever in patients presenting with cellulitis and skin rash. [ncbi.nlm.nih.gov]

  Scarlet fever is a streptococcal disease characterized by a bright red skin rash, fever and sore throat. It's most common in children under 10. [web.archive.org]

  Desquamation of face, skin folds, hands and feet Desquamation may last up to 6 weeks VI. [fpnotebook.com]

• Eruptions

  The clinical picture mimicked that of drug eruption after treatment of cellulitis with antibiotics. [ncbi.nlm.nih.gov]

  2016 2017 2018 2019 Billable/Specific Code Type 1 Excludes specified type of rash- code to condition vesicular eruption ( R23.8 ) canker A38.9 scarlet A38.9 Scarlatina (anginosa) (maligna) A38.9 Scarlet fever A38.9 (albuminuria) (angina) ICD-10-CM Codes [icd10data.com]

  A rapidly erupting rash appears 1 to 2 days after the onset of the sore throat. The rash displays as pinhead-size red lesions, which rapidly cover the body except for the face. [medical-dictionary.thefreedictionary.com]

  Pathophysiology As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness. [emedicine.com]

• Petechiae

  Other signs include enlarged papillae on the tongue (strawberry tongue) and petechiae on the soft palate. Treatment The risks from these complications provide strong support for an early diagnosis and immediate treatment. [tandfonline.com]

  Signs Forehead and cheeks appear flushed Circumoral pallor Pharyngitis Tonsil s are hyperemic and edematous, with exudate Throat is inflamed and covered by a membrane Palatal Petechiae may be present Strawberry Tongue Fine Papule s on Tongue surface Tongue [fpnotebook.com]

  Scarlet‑colored maculopapular exanthem (rash) Presentation Fine, erythematous, sandpaper‑like texture Blanches with pressure Nonblanching petechiae are often additionally present May be pruritic Pastia's lines A key sign of scarlet fever: linear, petechial [amboss.com]

• Eczema

  It has been shown to be effective against MRSA, supports a healthy digestive system, helps heal eczema and acne, and fights tooth decay and bad breath. [draxe.com]

• Circumoral Pallor

  In addition to this flushed appearance, there is usually a pale area around their mouth (circumoral pallor). Circumoral Pallor Another finding is dark, hyperpigmented areas on the skin, especially in skin creases. [atsu.edu]

  Also remember, that there is pallor around the face in the presence of the flushed/red face. This pallor is called circumoral pallor. Following signs and symptoms can be observed: 1. Fever. 2. Sandpaper rash on the body and possibly limbs. 3. [youtube.com]

  Signs Forehead and cheeks appear flushed Circumoral pallor Pharyngitis Tonsil s are hyperemic and edematous, with exudate Throat is inflamed and covered by a membrane Palatal Petechiae may be present Strawberry Tongue Fine Papule s on Tongue surface Tongue [fpnotebook.com]

  The face is flushed but a pale zone is left around the mouth (circumoral pallor). The tongue has a white coating with red spots. As the rash fades there is skin peeling. [medical-dictionary.thefreedictionary.com]

  The rash does not appear on the palms or soles of hands and feet, nor on the face, which is brightly flushed with a pale area circling the mouth (circumoral pallor). The rash usually lasts four to five days and then fades away. [science.jrank.org]

• Epistaxis

  Skin hemorrhaging, hematuria, and epistaxis occurred in patients with the hemorrhagic form of scarlet fever. These symptoms typically occurred within the first two to three days of the illness. [uspharmacist.com]

• Neck Swelling

  A patient with an abscess experiences an abrupt increase in pain and dysphagia, neck swelling, and fever after the initial symptoms of pharyngitis. Prompt treatment is recommended to prevent fatal necrotizing fasciitis of the neck. [uspharmacist.com]

• Headache

  Early warning signs include sore throat, headache and fever, flushed cheeks and swollen red 'strawberry' tongue with the characteristic pinkish/red sandpapery rash. [dailymail.co.uk]

  The symptoms of scarlet fever begin with a sore throat, a fever of 101 to 104 degrees Fahrenheit (38.2–40 degrees Celsius), and headache. This is followed within twenty-four hours by a red rash covering the trunk, arms, and legs. [healthychildren.org]

  You may also have headache, body aches, and a fever. Untreated, the streptococcal bacteria can spread to other parts of the body, causing blood stream infection, pneumonia, and other complications. [fairview.org]

  Headache. -Nausea or vomiting. -Body aches and pain. -A general feeling of unwell. -Loss of appetite. -Swollen neck glands. [irishhealth.com]

Laboratory tests

• Complete blood count
• ESR
• Urinalysis
• Throat culture: According to the American Heart Association, signs of group A streptococci (GAS) are always found in throat cultures in acute infections [9]. 
• Anti-deoxyribonuclease B antibody titres
• Anti-streptolysin-O titres

Imaging 

Imaging studies are not required to diagnose scarlet fever.

Test results

On the basis of results of throat culture and antibody testing, a diagnosis can be made.

Most scientists recommend penicillins, like benzylpenicillin and phenoxymethylpenicllin as drugs of first choice for effective treatment of Streptococcus tonsillopharyngitis and scarlet fever [3]. Erythromycin may be considered as an alternative drug if patients are resistant or allergic to penicillin or 1st generation cephalosporins [10]. A 10 day course of the antibiotics is generally sufficient to treat the infection. Patients should also be kept isolated during the course of the disease to prevent transmission.

Scarlet fever has an excellent prognosis. The fever persists for 3 to 6 days and the rash begins to desquamate and peel off on its own, fading after around 6 days. The disease is completely eradicated from the body with the help of a 10 day course of antibiotics.

Scarlet fever is considered an infectious, toxin-mediated disease whose pathogenicity depends upon production of specific exotoxins [2].

Causative agent

The main causative agent of scarlet fever is a gram positive bacterium called Streptococcus pyogenes, which belongs to the β-hemolytic group A streptococci, and is a natural colonizer of the human nasopharynx and oral cavity. S. pyogenes causes the widest range of infectious diseases in humans among all known bacterial pathogens [3]. Other members of the group A streptococci are also implicated in causing scarlet fever.

Transmission

There has been a confirmed outbreak of person-to-person transmitted scarlet fever, and the main risk factor was having a relative with tonsillitis [4]. Transmission is mainly air borne; via inhaled aerosol droplets containing the infectious agents, but the illness can be also be food borne.

Incidence

Increases in scarlet fever above usual seasonal levels are currently being seen across the United Kingdom [5]. Worldwide, around 10% of people are likely to get a throat infection from group A streptococci, and only 10% of these people are likely to develop scarlet fever.

Age

Scarlet fever is a rare disease in adult patients [6]. It typically affects young children between 5-15 years. Usually as the child reaches 10 years of age and above, antibodies to GAS strains are developed and circulated in the body, making the child fairly immune to further infections by the same bacteria.

Sex

This disease affects males and females equally.

The infective organisms may be inhaled or ingested, and after infection by a strain of group A streptococci, an incubation period of 1 to 4 days takes place. The bacteria produce pyrogenic toxins that cause the characteristic rash and fever. According to a retrospective study conducted in Taiwan, the frequencies of pyrogenic exotoxin genes were 9.5% for speA, 81.0% for speB, 4.8% for speC, and 71.4% for speF in isolates from patients of scarlet fever [7]. Inflammatory process begins which contributes to the redness of the rash. Patients are infective both during this as well as the subclinical period.

Scarlet fever has no vaccine available. Because of the wide distribution of S. pyogenes in the general population and the lack of an effective vaccine, possibilities for prevention allowing a suitable protection for diseases due to S. pyogenes are very limited [3]. 

Scarlet fever is one of a variety of diseases caused by group A streptococcus (GAS) [1]. It may be endemic, epidemic or sporadic and indeed many outbursts throughout the world have been reported in the past years. Scarlet fever is usually associated with pharyngitis which is the primary mode of illness by species of the group A streptococci, and often occurs after a throat infection. Although it is now perfectly treatable with the help of antibiotics that target gram positive bacteria, scarlet fever was a source of high mortality in the past. 

Definition

Scarlet fever is a streptococcal disease characterized by a skin rash in children. It can be endemic, epidemic or sporadic [3].

Cause

It is caused by bacteria belonging to group A Streptococci, which are gram positive strains and many are normally present in the nasopharynx.

Signs and symptoms

Scarlet fever begins with a sore throat which then progresses to a fever and a characteristic rash all over the body. The tongue becomes bright red and is called strawberry tongue. The infection persists for 3-6 days and the rash begins to peel off after 5-6 days.

Diagnosis

Diagnosis can be made clinically if characteristic signs are present. Throat culture is considered gold standard for diagnosis and antibody testing can also aid the diagnosis.

Treatment

Treatment is a course of antibiotics for 8-10 days along with bed rest and avoidance of public places to reduce the chances of transmission.

1. Yang P, Peng X, Zhang D, Wu S, Liu Y, Cui S, Lu G, Duan W, Shi W, Liu S, Li J, Wang Q. Characteristics of group A Streptococcus strains circulating during scarlet fever epidemic, Beijing, China, 2011. Emerg Infect Dis. 2013 Jun;19(6):909-15. 
2. Silva-Costa C, Carriço JA, Ramirez M, Melo-Cristino J. Scarlet fever is caused by a limited number of Streptococcus pyogenes lineages and is associated with the exotoxin genes ssa, speA and speC. Pediatr Infect Dis J. 2014 Mar;33(3):306-10. 
3. Stock I. Streptococcus pyogenes--much more than the aetiological agent of scarlet fever. [Article in German]. Med Monatsschr Pharm. 2009 Nov;32(11):408-16. 
4. Fernández-Prada M, Martínez-Diz S, Colina López A, Almagro Nievas D, Martínez Romero B, Huertas Martínez J. Scarlet fever outbreak in a public school in Granada in 2012. An Pediatr (Barc). 2014 Apr;80(4):249-53.
5. Guy R, Williams C, Irvine N, Reynolds A, Coelho J, Saliba V, Thomas D, Doherty L, Chalker V, von Wissmann B, Chand M, Efstratiou A, Ramsay M, Lamagni T. Increase in scarlet fever notifications in the United Kingdom, 2013/2014. Uro Surveill. 2014 Mar 27;19(12):20749. 
6. Sandrini J, Beucher AB, Kouatchet A, Lavigne C. [Scarlet fever with multisystem organ failure and hypertrophic gastritis]. Rev Med Interne. May 2009;30(5):456-9
7. Wu PC, Lo WT, Chen SJ, Wang CC. Molecular characterization of Group A streptococcal isolates causing scarlet fever and pharyngitis among young children: a retrospective study from a northern Taiwan medical center. J Microbiol Immunol Infect. 2014 Aug;47(4):304-10. 
8. Robbins and Cotran. Pathologic Basis of Disease. 8th ed. Philadelphia, Pa: Saunders Elsevier, 2010. ISBN 978-1-4160-3121-5
9. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51
10. Bass JW. Antibiotic management of group A streptococcal pharyngotonsillitis. Pediatr Infect Dis J. Oct 1991;10(10 Suppl):S43-9