A child presents with scarlet fever. All of the following are recognised features EXCEPT one. Which is the EXCEPTION?

Correct answer: C. Spontaneous gingival bleeding

• A. This IS a feature. The tongue is initially coated white with prominent red fungiform papillae (white strawberry tongue); as the coating desquamates around days 4–5 the classic RED STRAWBERRY (raspberry) TONGUE appears.
• B. This IS a feature. Facial flushing with a pale ring around the mouth — CIRCUMORAL PALLOR — is classic.
• C. CORRECT — this is the EXCEPTION. SPONTANEOUS GINGIVAL BLEEDING is not a feature of scarlet fever. It points instead toward a haematological disorder (leukaemia, thrombocytopenia), severe vitamin C deficiency, or necrotising gingivitis.
• D. This IS a feature. The rash of scarlet fever is a fine, diffuse, blanching erythema with a characteristic sandpaper texture, beginning on the trunk and accentuated in the flexures (Pastia's lines).

Note: Scarlet fever is group A beta-haemolytic streptococcal pharyngitis plus an erythrogenic exotoxin. It is treated with penicillin, principally to prevent the non-suppurative sequelae — acute rheumatic fever and post-streptococcal glomerulonephritis. Desquamation of the hands and feet follows in convalescence.