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Table of Contents
Peaks 5-15 years old in winter and early spring
In children <3 yo, exudative strep pharyngitis is rare, infection more commonly presents as coryza, excoriated nares, and generalized adenopathy
"Scarlet fever" occasionally accompanies strep pharyngitis and appears as a finely papular erythematous rash that spares the face, may be accentuated in skin folds, and may desquamate during convalescence
Severe unilateral pain or swallowing difficulty should raise concern about a local complication (e.g. peritonsillar or retropharyngeal abscess), particularly if the symptoms arise or progress several days into the illness
Likelihood of positive Group A Strep throat culture
Cough, runny nose/congestion, and conjunctivitis are not typical symptoms of strep pharyngitis, and, if present, they suggest an alternative cause
Periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome - important non-infectious cause, occurs primarily <5 years old, episodes usually <5 days, recur at regular intervals of 3-6 weeks, and includes acute fever, pharyngitis plus tender cervical LAD, or aphthous ulcers.
Rapid strep antigen detection test of a throat swab specimen - sensitivity 70-90%, specificity 95%, immediate results
Throat culture - more sensitive and specific than rapid test but requires 1-2 days for results
Serum antibodies to streptolysin O or DNase B
Useful for retrospective diagnosis of strep infection in cases of acute rheumatic fever or poststrep glomerulonephritis
Titers do not begin to increase until 7-14 days after the onset of infection, peak in 3-4 weeks
Consider evaluation for infectious mononucleosis (EBV) due to significant overlap
Monospot (heterophile IgM)
Negative in 50-75% of children <12 years old with EBV, good sensitivity (85%) and specificity (94%) in older children
Monospot typically negative with other causes of infectious mono (CMV, HHV-6, HIV, Toxoplasma gondii)
CBC with differential - atypical lymphocytes of
10% on a peripheral-blood smear has a sensitivity of 75% and a specificity of 92% for the diagnosis of infectious mono
In the absence of clinical findings of infection, a positive culture or rapid test is likely due to incidental carriage of strep
Strep can be cultured during winter months in ~10% of healthy school age children (less frequently in persons in other age groups). Carriage can persist for weeks or months and is associated with a very low risk of complications or transmission to others.
Rest, fluids, acetaminophen or ibuprofen for pain, gargle salt water, etc.
Self-limited in most cases even without antibiotics, but treatment reduces risk of subsequent acute rheumatic fever and development of local abscesses
Recurrence despite treatment
Repeat testing and treatment (if tests positive) are indicated
Recurrence may result from reinfection from a household contact who is a carrier. Many experts recommend throat cultures from household contacts and treatment of all carriers if reinfection is suspected.
Clindamycin and cephalosporins appear to be more effective than penicillin in eradicating carriage, and these agents are preferred in this situation.
Strep can persist for days on toothbrushes but effectiveness of replacing brushes is unknown. There is no convincing evidence that household pets are a source of recurrent infection.
indicated in certain cases
Streptococcal Pharyngitis - NEJM 2011.pdf
ASO and Anti-Deoxyribonuclease B Titers- Normal Values for Children Ages 2 to 12 in the US - Pediatrics 1998.pdf
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