Hepatitis and Hematuria in Scarlet Fever
Ayla Giiven
Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey.
Abstract, Scarlet fever is a common and usually benign course when treated properly. Hepatitis due to scarlet fever has
been described mostly in adults. A 21/2-year-old boy presented with scarlet fever and jaundice, hematuria and elevated
liver enzymes. [Indian J Pedlatr 2002; 69 (11) : 985-986]
Key words : Scarlet fever; Hepatitis; Hematuria
Infection with group A beta-hemolytic streptococci
(GABHS) is the most common bacterial cause of acute
upper respiratory tract infection during childhood.
Erythrogenic toxin-producing GABHS strains can cause
scarlet fever. Scarlet fever is a common and is usually not
a serious illness when treated properly and lasts a week or
less. Very rarely the bacteria spread to the other parts of
the body in spite of treatment and cause complications
such as ear infections, sinusitis, rheumatic fever or acute
glomerulonephritis.1Association of hepatitis with scarlet
fever has been described mostly in adults. 2~ The author
reports a boy who presented with this manifestation.
CASE REPORT
'A 21/2-year-old boy was admitted to our hospital with
complaints of fever, rash and dark urine for two days. He
had sore throat and fever 10 days ago and had not
received any treatment. On admission, the patient was
febrile (temperature 38.8 ~ and his weight and length
were w i t h i n normal ranges. Physical examination
revealed jaundice,tonsillopharyngitis, white strawberry
tongue, maculopapular eruptions on his trunk and
extremities. Perioral area was pale. There were Pastia's
lines on his antecubital regions and lymhadenopathies
with diameter of 0.5-1 cm on both cervical and
submandibular regions. The liver was palpable 1 cm
below the costal margins.
Laboratory tests revealed hemoglobin (Hb) 11 g/dl,
leukocytes 5 x 109/L with 68 % neutrophils, 3%
monocytes, 29% lymphocytes and 23x 109/L; erythrocyte
sedimentation rate (ESR) of 42 mm/h; serum C-reactive
protein (CRP) was 12 mg/dl (normal values:<0.5 mg/dl).
Antistreptolysine O (ASO) titer was elevated to 420 IU/
ml. Beta hemolytic streptococci were isolated from throat
swab culture. Liver enzymes were elevated (AST 137 U/
L, ALT 159 U/L, GGT 141 U/L) and serum biluribin was
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Ankara, Turkey,Fax : +90 312 215 0143,
E-mail : guvenayla@yahoo.com.
Indian Journal of Pediatrics, Volume 69~November, 2002
4.1 m g / d l with 1.8 m g / d l of conjugated bilirubin.
Alkaline phosphatase (521 U/L) and LDH (225 U/L) were
within normal ranges. Urinalysis revealed specific gravity
1020, pH 6, protein (++), bilirubin (++), urobflinogen (+),
and 5-6 leukocytes with 20-25 erythrocytes/high power
field. Serology including hepatitis viruses A, B, C,
Epstein-Barr virus (EBV), parvovirus B 19 and
cytomegalovirus (CMV), was negative. Complement-3
level (125 mg/dl) was normal. Ultrasound examinations
of the abdomen were unremarkable. The patient was
treated with intravenous penicillin G (400000 U/kg/day)
for 10 days. He became afebrile on the third day.
Leukocytes, erythrocytes and bilirubin in the urine and
hepatomegaly dissapeared on the fourth day of therapy.
Liver enzymes and serum b'flirubin became normal (ALT
32 U / L , AST 25 U / L , GGT 14 U / L , and 0.7 m g / d l ,
respectively ) on the seventh day. He was discharged
within 10 days.
DISCUSSION
Hepatitis due to scarlet fever is rare in children),*
Althought it is well established that scarlet fever may
present with hepatitis, published reports usually concern
cases in adulthood2~It was first described by Mac Mahon
and Mallory in 1931.6
Patient with severe scarlet fever should be treated with
intravenous penicillin as our patient was treated with this
drug.
Elevated liver transaminases have also been in invasive
GABHS infections which is indicative of hepatic
involvement7 Hepatitis due to scarlet fever has a benign
course and usually resolve within a week. Liver biopsy
had been done in scarlet fever. Microscopically liver
consists of polymorphonudear granulocytes infiltration in
the portal areas. Degeneration of the hepatocytes is often
seen. 3 The pathogenesis of liver involvement in scarlet
fever remains obscure. Invasive group Astreptococci may
cause direct toxic injury on the hepatocytes,s
Hematuria in the absence of glomerulonephritis in
985
 Ayla GOven
scarlet fever has b e e n described as seen i n 1.1% of cases?
Robbens a n d colleague reported two a d u l t patients w i t h
severe k i d n e y a n d liver i n v o l v e m e n t d u r i n g scarlet fever. 2
The patient h a d hematuria, which m i g h t be a s y m p t o m of
renal involvement. Because his blood pressure was w i t h i n
normal limits and complement level was normal,
nephritis w a s n o t considered.
As in of this case, the possibility of hepatitis s h o u l d be
kept in m i n d in patients w i t h scarlet fever with j a u n d i c e
a n d elevated liver enzymes.
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Indian Journal of Pediatrics, Volume 69--November, 2002