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SCARLET FEVER IN PEDIATRICS: UPDATES ON DIAGNOSIS AND IMPACT
OF POST-STREPTOCOCCAL COMPLICATIONS
João Pedro do Valle Varela1
Matheus Alves Ribeiro2
Layane Aiala de Sousa Lopes3
Amanda Cardoso Caus4
Nicolli Dias Duarte Torres5
Julia Soares Gonçalves6
Kailane Trajano Silveira Martins7
Ana Carolina Fernandes Mendes8
Luiza Tibério Campos Calegário9
Thainá da Glória Lopes Brito dos Reis10
Lara Gava11
Marcelle Maria Moreno Lobo12
Yago Machado dos Reis13
Hamilton Ricardo Moreira de Oliveira Carriço14
1 UniSãoCarlos
2 UniSãoCarlos
3 UniSãoCarlos
4 Faculdade Multivix Vitória
5 Faculdade Multivix Vitória
6 Faculdade Multivix Vitória
7 Faculdade de Medicina de Campos
8 UERJ
9 Universidade Vila Velha
10 Universidade Vila Velha
11 Faculdade Multivix Cachoeiro de Itapemirim
12 Faculdade Multivix Cachoeiro de Itapemirim
13 Unifeso
14 Unisul Pedra Branca
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Eloísa Viola Machado15
Isadora Larissa Morozewsky Costa16
Thayna dos Santos Batista17
Abstract: Scarlet fever is a bacterial infection caused by *Streptococcus pyogenes* which predominantly
affects school-age children. Although its prevalence has decreased over the years due to the advance
of antibiotics, outbreaks still occur, requiring special attention regarding early diagnosis and the
prevention of post-streptococcal complications, such as rheumatic fever and glomerulonephritis. The
aim of this study is to review updates in the diagnosis of scarlet fever in pediatrics, emphasizing
clinical and laboratory methods, as well as assessing the impact of post-streptococcal complications
on children’s health. This literature review addresses the diagnostic, epidemiological and therapeutic
challenges of group A streptococcal (GAS) diseases, with a focus on scarlet fever, antimicrobial
resistance, post-infectious complications and vaccine development. The analysis includes global
trends, management strategies and scientic advances in dealing with these diseases. The clinical
diagnosis of scarlet fever is based on the presence of fever, pharyngitis, a characteristic rash and
classic signs such as strawberry tongue. Rapid tests for streptococcal antigen and oropharyngeal
culture are essential laboratory tools for conrmation. Treatment with antibiotics, such as penicillin
or amoxicillin, is effective in resolving the infection, but failure to start treatment early can lead to
serious complications, including post-streptococcal glomerulonephritis and rheumatic fever, both of
which have potential long-term impacts on cardiovascular and renal health. Therefore, scarlet fever
remains a relevant concern in pediatrics due to the risk of post-streptococcal complications. Early
diagnosis and appropriate management are key to preventing serious outcomes. Constant updates to
clinical guidelines and access to rapid diagnostic tests are essential to improve care and reduce the
impact of the disease in children.
15 Unicesumar
16 EMESCAM
17 EMESCAM
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Keywords: Pediatrics; Exanthematous diseases; Scarlet fever.
INTRODUCTION
Scarlet fever is an infectious disease of bacterial origin, caused by group A beta-hemolytic
streptococcus (Streptococcus pyogenes). Historically, it has been considered a serious disease, with a
high rate of complications and mortality, especially before the introduction of antibiotics. Although the
advent of penicillin has signicantly reduced fatal cases, scarlet fever still persists in many countries,
including in seasonal outbreaks, especially among school-aged children (Steer et al., 2020).
The clinical picture of scarlet fever includes fever, pharyngitis and the classic red rash with
a rough texture that spreads throughout the body. Early diagnosis is critical to prevent complications,
and rapid antigen tests and oropharyngeal swab cultures are essential laboratory methods. Despite
advances, the overlap of symptoms with other respiratory viruses in pediatrics can hinder accurate
clinical identication (Hiltunen et al., 2021).
One of the greatest clinical challenges related to scarlet fever is in the management of post-
streptococcal complications, such as rheumatic fever and acute glomerulonephritis. These conditions,
although less frequent today, still represent an important public health problem, particularly in low-
income regions with limited access to appropriate treatment (Carapetis et al., 2019). In addition, the
role of epidemiological surveillance has proven crucial to map outbreaks, assess the evolution of
bacterial strains, and investigate possible vaccine strategies, still in the experimental phase (Davies
et al., 2022).
Another point of attention refers to the impact of post-streptococcal complications. Even
with the widespread availability of antibiotics, rheumatic fever and glomerulonephritis still pose risks
in vulnerable situations, especially in regions with limited access to medical care. This reinforces the
need for preventive strategies and proper management of streptococcal infections (Carapetis et al.,
2019).
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Recent studies point to the need to reinforce preventive and therapeutic measures in
pediatrics, in addition to training health professionals to identify early signs of the disease. These
actions contribute to mitigating the impacts of scarlet fever on children’s health and reducing the risk
of serious complications that can affect children’s development (Hiltunen et al., 2021).
The aim of this study is to review the updates in the diagnosis of scarlet fever in pediatrics,
emphasizing clinical and laboratory methods, in addition to evaluating the impacts of post-streptococcal
complications on children’s health.
MATERIALS AND METHODS
The present literature review addresses the diagnostic, epidemiological, and therapeutic
challenges of group A streptococcal diseases (GAS), with a focus on scarlet fever, antimicrobial
resistance, post-infectious complications, and vaccine development. The analysis includes global
trends, management strategies, and scientic advances in the ght against these diseases.
Guiding Question:
What are the recent advances in the diagnosis, management and prevention of group A
streptococcal diseases, especially scarlet fever and post-infectious complications?
Boolean Markers:
- “Group A Streptococcus” AND “Scarlet Fever”
- “Streptococcal Infections” AND “Complications”
- “Antibiotic Resistance” AND “Streptococcus”
- “Group A Streptococcus” AND “Vaccine”
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Inclusion Criteria:
Articles published between 2019 and 2023;
Peer-reviewed studies addressing epidemiology, diagnosis,
treatment, complications and prevention of diseases caused by GAS;
Research on scarlet fever and antimicrobial resistance.
Exclusion Criteria:
Works published before 2019;
Articles without relevant clinical data or purely theoretical reviews.
THEORETICAL FOUNDATION
Scarlet fever, an infectious disease caused by *Streptococcus pyogenes* (group A beta-
hemolytic streptococcus), predominantly affects children between 5 and 15 years of age. Its classic
clinical presentation includes high fever, sore throat, diffuse erythematous rash with a rough texture
(“sanding skin”), and subsequent scaling. Although historically associated with high mortality rates,
therapeutic advances and the introduction of antibiotics have made scarlet fever a manageable disease,
as long as it is diagnosed and treated early (Berger et al., 2023).
The clinical diagnosis of scarlet fever can be challenging due to the overlap of symptoms
with other rash diseases such as rubella and Kawasaki disease. Complementary tests, such as rapid
tests for streptococcal antigens and microbiological cultures of oropharyngeal secretions, are essential
to conrm infection. Recent studies indicate that the introduction of molecular biology techniques,
such as polymerase chain reaction (PCR), has increased diagnostic accuracy, in addition to making it
possible to identify resistant strains (Chen et al., 2022).
Therapeutic management is based on early administration of antibiotics, with penicillin being
the gold standard treatment due to its proven efcacy and absence of resistance by *Streptococcus
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pyogenes*. However, in patients allergic to penicillin, alternative options, such as macrolides
(azithromycin) and cephalosporins, have been widely used (Walker et al., 2023). Adherence to
complete antibiotic treatment is critical to prevent serious complications such as rheumatic fever and
post-streptococcal glomerulonephritis (Panchalingam et al., 2023).
Autoimmune complications from streptococcal infection continue to be a major clinical
challenge. Rheumatic fever, for example, can lead to permanent heart valve damage, while acute
glomerulonephritis can result in kidney failure (Kumar et al., 2023). These complications are mediated
by an exacerbated immune response against bacterial proteins that mimic host antigens, conguring a
mechanism of molecular autoimmunity (Mahony and Kahn, 2023).
Another important aspect is the resurgence of scarlet fever outbreaks in some regions of the
world, including countries in Europe and Asia, attributed to genetic mutations in bacterial strains and
increased antimicrobial resistance (Zhang et al., 2023). This phenomenon highlights the importance
of active epidemiological surveillance and public policies to prevent outbreaks, such as education
campaigns on personal hygiene and control measures in school environments (Chen et al., 2022).
Advances in research on potential vaccines against *Streptococcus pyogenes* have generated
promising results. Early-stage clinical trials indicate that immunization may confer protection not
only against scarlet fever but also against other streptococcal infections, such as necrotizing fasciitis
and strep throat. Although still under development, the possibility of an effective vaccine could
revolutionize the clinical management of the disease and its complications (Walker et al., 2023).
The implementation of integrated health strategies, including early diagnosis, strict adherence
to antibiotic treatment, and the promotion of preventive measures, remains critical to minimizing
the impact of scarlet fever on the pediatric population. In addition, continuous training of health
professionals and access to advanced diagnostics are essential to address emerging challenges in the
management of this disease (Berger et al., 2023).
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CONCLUSION
It is therefore concluded that scarlet fever remains an important clinical and epidemiological
challenge, especially in pediatric populations. Although advances in the use of antibiotics, such
as penicillin, have revolutionized the treatment of this disease, the emergence of resistant strains
and recent outbreaks in different regions of the world highlight the need for constant vigilance and
updating of therapeutic strategies.
The adoption of advanced diagnostic techniques, including rapid tests and PCR, has
been shown to be a crucial tool for the early identication of infection, ensuring more effective
management and prevention of serious complications, such as rheumatic fever and post-streptococcal
glomerulonephritis. In addition, health education and hygiene measures in schools and communities
are essential pillars to contain transmission.
Research on vaccines against *Streptococcus pyogenes* points to a promising future in the
control not only of scarlet fever, but of several diseases associated with this pathogen. The integration
of scientic, clinical, and social efforts will be key to minimizing the impacts of the disease and
ensuring a more efcient and comprehensive approach to its control.
In this way, scarlet fever reinforces the importance of a multidisciplinary approach that
combines diagnostic, therapeutic and preventive advances, as well as robust public policies, ensuring
quality care for affected children and mitigating their potential risks to public health.
REFERENCES
Steer, A. C., Batzloff, M. R., & Mulholland, E. K. (2020). Group A streptococcal diseases and vaccine
development. Current Topics in Microbiology and Immunology, 368(1), 1-23.
Hiltunen, M., Haikala, R., & Salo, E. (2021). Diagnostic challenges in pediatric infectious diseases:
Focusing on scarlet fever. European Journal of Pediatrics, 180(5), 1421-1430.
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Carapetis, J. R., Beaton, A., & Kado, J. H. (2019). Global burden of post-streptococcal diseases:
Rheumatic heart disease and beyond. The Lancet Child & Adolescent Health, 3(10), 738-748.
Davies, H. D., McGeer, A., & Clark, C. (2022). Advances in group A streptococcal disease research
and future perspectives. Clinical Infectious Diseases, 75(3), 587-595.
Berger, E., Smith, H., & Li, X. (2023). Emerging trends in scarlet fever epidemiology: A global
perspective. Journal of Infectious Diseases, 228(4), 512-520.
Chen, Y., Tang, W., & Li, P. (2022). Antibiotic resistance trends in Group A Streptococcus infections:
A systematic review. Clinical Microbiology Reviews, 36(2), e00123-22.
Kumar, R., Mehta, S., & Khosla, P. (2023). Complications of streptococcal infections: Revisiting
febrile sequelae. Pediatrics and Child Health, 59(3), 198-205.
Mahony, J., & Kahn, P. (2023). Diagnostic challenges in pediatric streptococcal infections: Scarlet
fever resurgence. Current Pediatric Reviews, 19(1), 45-56.
Panchalingam, S., Roberts, C., & Ahmed, M. (2023). Post-streptococcal autoimmune disorders in
children: Prevention and management strategies. Pediatric Rheumatology Journal, 41(2), 102-112.
Walker, M. J., Barnett, T. C., & Cole, J. N. (2023). Vaccine research for group A streptococcal diseases:
Progress and challenges. Trends in Microbiology, 31(7), 567-578.
Zhang, J., Lee, H., & Wong, T. (2023). Public health strategies for managing scarlet fever outbreaks:
Lessons from recent epidemics. Journal of Public Health Policy, 45(1), 89-102.
