Often presents as a syndrome of exudative pharyngitis, fever, and bright-red exanthem (rash on skin).

• Oropharynx/tonsillopharynx: ~1- to 4-day incubation period for strep throat then abrupt onset of fever and sore throat; nausea, vomiting, headache, and abdominal pain are possible, particularly in younger children; beefy-red, enlarged tonsils with possible petechiae present on soft palate; white strawberry tongue on first 2 days then and red strawberry tongue; often tender anterior cervical adenopathy.
  
• Skin: 1 to 2 days after fever onset can see erythematous patches develop on neck and upper trunk; by ~day 4 classic erythematous, rough, sandpaper-like rash rapidly develops on trunk and extremities; circumoral pallor also possible; accentuation often occurs in skin folds with some linear purpura referred to as Pastia lines; rash lasts ~4 to 5 days then will see desquamation that resolves over 1 to 2 weeks but can sometimes take a month to clear and often dramatic peeling of the palms and soles.
  
• Gastrointestinal: Mesenteric lymphadenopathy can mimic “acute abdomen.”

10- to 14-day course of oral antibiotics indicated, generally rapid clinical improvement.

• Penicillins are the drugs of choice unless documented allergy; penicillin VK 250 mg bid in children, 500 mg bid for adolescents; intramuscular penicillin (benzathine penicillin G) is an option if necessary (<27 kg 600,000 units IM ×1 dose; >27 kg 1.2 million units IM ×1 dose); amoxicillin 25 to 30 mg/kg/day based on weight divided bid, if >40 kg then 500 mg bid.
  
• First-generation cephalosporins may be effective; cephalexin 25 to 50 mg/kg/day divided q6-8h (max 4 g/day).
  
• Clindamycin and macrolides are also effective options though some GABHS resistance can be seen to the latter; erythromycin has also been used but resistance and GI toleration issues are also possible.
  
• Simple emollients for desquamation.

• Skin: Short-lived, erythematous, annular lesions with raised edges and central clearing over time; adjacent lesions expand and meet and tend form larger annular and polycyclic lesions (rings of various sizes); can also form rings within rings, commonly on abdomen, chest, and limbs but almost never on face; usually appears at the onset of acute attack of ARF or relapse; frequently is present when there are no other signs of active infection and ESR is normal, will often come and go and can last from 1 or 2 days to months or years.
  
• Systemic: Five major clinical criteria for ARF (Jones criteria):
  
  
  
  1. Carditis and valvulitis (pancarditis) clinical or subclinical (50%-70%).
     
  2. Migratory polyarthritis involving the large joints (35%-66%).
     
  3. Central nervous system involvement/Sydenham chorea (10%-30%).
     
  4. Subcutaneous nodules (up to 10%).
     
  5. Erythema marginatum (6%-10%).

Minor criteria:

1. Arthralgia.
   
2. Fever.
   
3. Elevated acute phase reactants (ESR and C-reactive protein).
   
4. Prolonged PR interval on electrocardiogram.

To make the diagnosis of ARF, a patient needs 2 major criteria or 1 major plus 2 minor criteria.

Treat the underlying streptococcal infection to reduce nonsuppurative complications; risk of rheumatic fever recurrence is greatest during the first 3 to 5 years; prophylaxis is recommended indefinitely in patients with established heart disease or if frequently exposed to streptococci.

• Standard treatment of GABHS: Penicillin VK (oral), benzathine penicillin G (intramuscular).Patients with a nonanaphylactic allergy to penicillin may be treated with a first-generation cephalosporin; those with anaphylactic reactions should be treated with clindamycin; oral macrolides may also be used.
  
• Treatment of ARF: Aspirin: Often for 6 to 8 weeks (until symptoms of ARF resolving and erythrocyte sedimentation rate [ESR]/CRP are normal), benzathine penicillin G 1.2 million units IM every 4 weeks (oral therapy is less reliable), oral cephalosporins in penicillin allergic patients; management of heart failure symptoms as recommended by a cardiologist.

Frequent prodrome of nonspecific upper respiratory symptoms, irritability, and occasionally low grade fever; high fever may indicate serious infection; 1- to 10-day incubation period.

• Skin: Early painful erythema in flexural areas (eg, skin folds of neck, axillae, inguinal and gluteal areas); spares mucosa; erythema may be difficult to detect in darker skinned patients; can become generalized within ~48 hours; erythema progresses to flaccid blisters and bullae with wrinkling; erosions and desquamation are possible from minor trauma to the skin (Nikolsky sign); crusting and fissuring around mouth, nose, and eyes.