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  • A 5-year-old boy presents to the emergency room with a rash. He has had a sore throat with fever for 2 days now. On physical exam, he has a diffuse erythematous sandpaper-like rash that blanches with pressure. His tongue is beefy-red. A rapid strep test was positive. As he is documented to be allergic to penicillin, he is prescribed cephalexin.
  • Clinical definition
    • acute bacterial infection with diffuse erythematous eruption associated with pharyngitis
  • Epidemiology
    • demographics
      • children
    • risk factors
      • exposure to Streptococcus pyogenes or other erythrogenic strains
  • Pathogenesis
    • delayed-type hypersensitivity to S. pyogenes exotoxin A
  • Associated conditions
    • streptococcal pharyngitis
  • Prognosis
    • rash usually fades within a week
    • desquamation may last several weeks
  • Symptoms
    • sore throat
    • fever
  • Physical exam
    • strawberry tongue
    • circumoral pallor
    • diffuse blanching erythema
    • sandpaper-like rash with small papules
      • spreads from the groin and armpits and to the trunk and extremities
      • spares the palms and soles
    • the rash is followed by desquamation
  • Labs
    • rapid streptococcal testing
    • throat culture may reveal streptococcal pharyngitis
  • Making the diagnosis
    • based on clinical presentation
  • Kawasaki disease 
    • distinguishing factors
      • hand and foot rash
      • prolonged fever
      • conjunctival injection
      • no association with streptococcal pharyngitis
  • Staphylococcal scalded skin syndrome
    • distinguishing factors
      • + Nikolsky sign
  • Management approach
    • identical to the treatment approach in patients with streptococcal pharyngitis
    • additional treatment for the rash is not needed
  • Medical
    • penicillin
      • indications
        • for all patients
        • prevention of acute rheumatic fever
      • drugs
        • penicillin V
        • amoxicillin
    • alternatives to penicillin
      • indications
        • for patients with penicillin allergies
        • prevention of acute rheumatic fever
      • drugs
        • cephalosporins
        • clindamycin
        • macrolides
  • Acute rheumatic fever or rheumatic heart disease

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