Strep Pharyngitis
Sore throat remains one of the most common presenting complaints of sick children. The typical clinical findings of streptococcal pharyngitis include:
• sudden onset
• sore throat and tonsils
• fever
• headache
• nausea, abdominal pain (occasionally vomiting)
• marked inflammation of pharynx and tonsils
• tonsillar hypertrophy with white exudate
• tender, enlarged cervical nodes
ize="3">• absence of conjunctivitis, coryza, cough, diarrhea
It is not necessary to obtain a throat culture or rapid antigen test on every child with a sore throat. Most physicians seeing a toxic child with tonsillar exudate will treat immediately.
For borderline cases the rapid antigen tests are convenient for both patient and doctor. Most of these rapid tests have almost no false positive results, but there will be a few false negatives (strep present but not detected); consequently, negative results must be confirmed by conventional culture.
Penicillin remains the recommended treatment (oral phenoxymethyl penicillin) for ten days. The objectives of treatment are:
• eradication of group A, beta-hemolytic strep (GABHS) from the upper respiratory tract
• prevention of suppurative sequelae (tonsillar abscess or lymphadenitis)
• prevention of spread to others
• shorten the course of illness
Scarlet fever is simply GABHS pharyngitis with a rash. The justification for and choice of antimicrobial therapy is the same for scarlet fever as for routine GABHS pharyngitis.
What to do about the carrier state is complex and determined case by case. Identification and eradication of GABHS carriage should be considered when
• there is a family history of rheumatic fever
• outbreaks of acute rheumatic fever or acute glomerulonephritis
• "ping-pong" spread of GABHS within a family
• a family is inordinately anxious about GABHS
• there are outbreaks of GABHS pharyngitis in closed communities
• tonsillectomy is being considered only because of chronic carriage of GABHS
(Gerber M. Strep pharyngitis: update on management. Contemporary Pediatrics 1997; 14:156-165)
COMMENT: The absence of upper respiratory/nasal symptoms is important in suspecting strep pharyngitis. The presence of abdominal pain has always intrigued me; I have never heard an explanation of the pathophysiology. Short course therapy of five days instead of 10 is being evaluated by several investigators but results are not yet available. — R.A.