In this case-based module, GP Dr Toni Hazell discusses how to recognise and manage two potentially serious illnesses that commonly present with acute fever and rash in primary care. Complete the full module on Nursing in Practice 365 today.
Learning objectives
This case-based module will support your knowledge and understanding of:
• The management of children with a fever but no obvious focus.
• The diagnosis of children who have a fever and a rash.
• Notification of infectious diseases.
Case 1: A child with a sore throat and a rash
Related Article: CPD – Case by case: Acute fever and rash in children
It is Monday morning. You are working as an ANP in primary care and a 7-year-old boy has been brought in to see you. Your history reveals that he has had a sore throat and temperature up to 39°C, which started on Saturday evening. He is the fourth child in the family and his mother is well used to managing viral respiratory tract infections, so she has been giving him paracetamol and plenty to drink. The only reason he has been brought in today is because a rather dramatic rash has developed on the chest, and his mother is now worried that there might be something more serious going on. You examine the boy – he looks unwell and flushed, and his throat is red, with some dark red spots on the roof of his mouth. The skin of his torso is red and feels very dry – you notice that at the top of the chest, the rash is darker in the creases of his neck.
1. What is the likely diagnosis?
This is a classic case of scarlet fever, caused by the bacteria Streptococcus pyogenes. It tends to occur in the winter in the UK and hit the headlines in 2022 when a particularly invasive strain of Streptococcus caused several deaths.1 In scarlet fever, the bacteria produces a toxin which causes the classic rash, often described as having a sandpaper like experience. The child will be unwell with a fever and sore throat, with the rash developing a couple of days after the other symptoms. It starts on the trunk, axillae and groin and can then spread to the extremities of the body, although it does not generally affect the palms of the hands or the soles of the feet. Other key features are darker lines where the rash affects skin creases (such as in the neck or the groin), the fact that the rash can desquamate (start to peel off) as it resolves, and that the child may have cervical lymphadenopathy and/or an enlarged, red swollen tongue, with petechiae on the palate.2
2. How is scarlet fever treated?
Anyone who works in primary care will know that most sore throats don’t need antibiotics – they are usually caused by viruses, and a 10-day course of antibiotics may do nothing, or only reduce symptom duration by a less than 24 hours.3
However, a child with a sore throat as part of scarlet fever is different and antibiotics should be used; in the pre-antibiotic area, significant complications such as rheumatic fever and meningitis were not uncommon, and mortality was around 30%.2 There is no need to routinely take a throat swab before treating as it is a clinical diagnosis, although this may be advisable if there is diagnostic uncertainty.4 Treatment is with 10 days of penicillin V, with a macrolide usually used for those who are allergic to penicillin.
3. You discuss this case with a GP, who confirms that your diagnosis and proposed management is correct – as you are leaving her room, she calls out ‘don’t forget to notify it’. What does she mean by this?
Scarlet fever is one of a list of notifiable diseases – these are infections which have the potential for significant transmission, so public health needs to be aware when they are occurring. Notification is done on suspicion of the infection, so if you had sent a throat swab, you would still notify before it came back.5 Registered medical professionals (doctors) have a legal duty to notify an infectious disease, but anyone in the practice can notify. It can be done online, or you may have a form saved to your computer which automatically brings in the patient demographics and can then be emailed to your local public health team. Notification must be done within 3 days, although some infections are classified as urgent and must be phoned through on the same day. Scarlet fever isn’t one of these; examples of urgently notifiable diseases include mpox, measles and food poisoning that is part of a larger outbreak.6 You notify the scarlet fever – as this is something you have never had to do before, you also take the time to quickly add it to your appraisal portfolio as a learning event.
Related Article: Lipid management: What primary care nurses need to know
To complete the full module and log CPD points visit Nursing in Practice 365.
Dr Toni Hazell is a GP in north London
References
- Guy R, Henderson K, Coelho J et al. Increase in invasive group A streptococcal infection notifications, England, 2022. Euro Surveill 2023 Jan;28(1):2200942
- Pardo S, Perera T. Scarlet Fever. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-
- NICE Sore throat (acute): antimicrobial prescribing. [NG84] Jan 2018
- UKHSA. Group A streptococcal infections: report on seasonal activity in England, 2023 to 2024. July 2024
- UKHSA. Report a notifiable disease. Sept 2024
- UKHSA. Notifiable diseases and how to report them. Sept 2024
Related Article: People with long-term conditions should have BMI check every year, says NICE
