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Clinical Summary

Reddened hypertrophied lingual papillae, called strawberry tongue, are primarily associated with scarlet fever caused by group A streptococcal enterotoxin. The tongue initially appears white with the erythematous papillae sticking through the white exudate. After several days, the white coating is lost and the tongue appears bright red. Other signs of group A streptococcal infection include fever, an exudative pharyngitis, a scarlatiniform rash, and the presence of Pastia lines (petechial linear rash in the skin folds). Kawasaki syndrome may also present with an injected pharynx and an erythematous strawberry-like tongue. It is essential to make the distinction between streptococcal infection and Kawasaki syndrome, since the latter is associated with a high incidence of coronary artery aneurysm if left untreated. Also important to consider is toxic shock syndrome, in which one-half to three-fourths of patients have pharyngitis with a strawberry-red tongue.


Strawberry Tongue. Note the white exudate with bulging red papillae. The white coating is eventually lost after several days, and the tongue then appears bright red. (Photo contributor: Michael J. Nowicki, MD.)

Management and Disposition

Rapid streptococcal immunoassay testing may help expedite the diagnosis. Pharyngeal cultures are useful for confirming the diagnosis. Antistreptolysin O (ASO) titers can be used for confirmation in the convalescent stage if the diagnosis is in question. Penicillin is the drug of choice for group A Streptococcus.


  1. Strawberry tongue initially appears white in color, with prominent red papillae bulging through the white exudate. After several days, the tongue becomes completely beefy red.

  2. Kawasaki patients may also present with conjunctivitis and discoloration of the palms and soles.


Strawberry Tongue. This patient with scarlet fever demonstrates the bright red appearance of strawberry tongue after most of the white exudate is lost. (Photo contributor: Kevin J. Knoop, MD, MS.)

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