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Pharyngitis due to Group A Beta-Hemolytic Streptococcus

Group A Beta-Hemolytic Streptococcal Pharyngitis


Presentation

  • METHODS: Patients aged 6 months to 18 years presenting to a pediatric ED with suspected GABHS pharyngitis were prospectively enrolled in the study.[ncbi.nlm.nih.gov]
  • A total of 578 children aged between 1 and 15 years with a mean of 6.3 or- 3.7 years, presenting with sore throat were enrolled in the study.[popline.org]
  • †Higher scores of the prediction model equal more severe presentation of the clinical feature.[acpjc.org]
Fever
  • No patient developed rheumatic fever or nephritis. Treatment-related adverse events were similar between the two groups; mild vomiting (2%) was most frequently reported.[ncbi.nlm.nih.gov]
  • Outbreak of acute rheumatic fever in northeast Ohio. J Pediatr 1987;111:176-9. [20.] Acute rheumatic fever among Army trainees. MMWR Morb Mortal Wkly Rep 1988;37:519-22. [21.][drplace.com]
  • Patients had at least 1 of pharyngeal erythema or exudate, tenderness of cervical lymph nodes, or fever.[acpjc.acponline.org]
Chills
  • Besides getting a fever, chills, and a throat that really hurts, people can develop some pretty nasty-looking white stuff at the very back of the throat where the bacteria have settled in.[study.com]
  • Symptoms include extreme tiredness, weakness, fever, chills, night sweats, and weight loss. The infection can progress, resulting in problems with heart function in some cases.[humanillnesses.com]
  • Symptoms of group A streptococcal infection Streptococcal sore throat (pharyngitis) Typical symptoms include of streptococcal sore throat include: a sore, red throat with thick pus-like fluid around the tonsils fever and chills enlarged and tender lymph[betterhealth.vic.gov.au]
  • Typical symptoms include fever (usually greater than 101.3 F), red throat, sore throat, headache, stomach ache, nausea, chills, malaise, loss of appetite, abnormal taste, swollen lymph nodes in the neck, and difficulty swallowing.[3,5] While a sore throat[austincc.edu]
  • Constitutional symptoms include fever and chills, myalgias, headaches and nausea. Physical findings may include petechiae of the palate, pharyngeal and tonsillar erythema and exudates, and anterior cervical adenopathy.[aafp.org]
Malaise
  • In older children several nonspecific signs and symptoms can be associated with the disease, including headache, nausea, abdominal pain, malaise and vomiting (especially in older children).[news-medical.net]
  • The first symptoms appear after the incubation period (1 – 3 days) and include headache, fever, nausea and general malaise. Stomach pain may also occur. Swollen tonsils are visible in the throat and soon become covered in white streaks of pus.[littledotapp.com]
  • Typical symptoms include fever (usually greater than 101.3 F), red throat, sore throat, headache, stomach ache, nausea, chills, malaise, loss of appetite, abnormal taste, swollen lymph nodes in the neck, and difficulty swallowing.[3,5] While a sore throat[austincc.edu]
  • Early symptoms of TSS are nonspecific and often begin with influenza-like symptoms of mild fever and malaise. However, TSS often suddenly advances with symptoms of high fever, nausea, vomiting, diarrhea, skin rash, and a low blood pressure.[medicinenet.com]
  • The majority of scarlet fever patients do experience associated symptoms of malaise, fever, head- ache, and abdominal pain, with or without vomiting. On examination, patients are not ill.[ahcmedia.com]
Infectious Mononucleosis
  • "Epstein-Barr virus infectious mononucleosis". Am Fam Physician. 70 (7): 1279–87. PMID 15508538. Archived from the original on 2008-07-24. Johnson BC, Alvi A (March 2003). "Cost-effective workup for tonsillitis.[en.wikipedia.org]
  • Sensitive and specificity not high enough to make the diagnosis without culture confirmation Differential Diagnosis of “Sore Throat” Group A beta-hemolytic Streptococcus Infectious Mononucleosis (EBV) Other bacterial and viral pharyngitis etiologies ([pedclerk.bsd.uchicago.edu]
  • Differential Diagnosis See Pharyngitis Causes Common other causes Infectious Mononucleosis Posterior cervical adenopathy, Fatigue and prolonged Pharyngitis Hand, foot and mouth disease Oral Lesion s, hand and foot skin lesions VIII.[fpnotebook.com]
  • Infectious mononucleosis. Consultant . 2000;40:134–136. Google Scholar 18. Breese BB. A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child . 1977;131:514–517. PubMed Google Scholar 19.[link.springer.com]
Constitutional Symptom
  • Constitutional symptoms include fever and chills, myalgias, headaches and nausea. Physical findings may include petechiae of the palate, pharyngeal and tonsillar erythema and exudates, and anterior cervical adenopathy.[aafp.org]
Cervical Lymphadenopathy
  • Patients were stratified according to the number of clinical features present by using modified Centor criteria, ie, history of fever, absence of cough, presence of pharyngeal exudates, and cervical lymphadenopathy.[ncbi.nlm.nih.gov]
  • Description of prediction guide During the clinical evaluation, the examining physician recorded 4 variables from the tested model: cervical lymphadenopathy, tonsillar swelling (2-category severity scale: absent or mild and moderate or severe), coryza[acpjc.org]
  • On clinical examination, patients with group A strep pharyngitis usually have Pharyngeal and tonsillar erythema Tonsillar hypertrophy with or without exudates Palatal petechiae Anterior cervical lymphadenopathy Patients with group A strep pharyngitis[cdc.gov]
Lymph Node Tenderness
  • Using data from all 453 patients, the groups did not differ for adverse effects, lymph node tenderness, abdominal pain, or recurrence.[acpjc.acponline.org]
Vomiting
  • Treatment-related adverse events were similar between the two groups; mild vomiting (2%) was most frequently reported.[ncbi.nlm.nih.gov]
  • Significant predictors of GABHS pharyngitis were: age 10-15 years, the presence of dysphagia, vomiting, pharyngeal exudate, and scarlatiniform rash.[popline.org]
  • In older children several nonspecific signs and symptoms can be associated with the disease, including headache, nausea, abdominal pain, malaise and vomiting (especially in older children).[news-medical.net]
  • Abdominal pain, nausea and vomiting may occur, although these symptoms are more characteristic of GABHS infection in children than in adults. Headache may be present, but cough, rhinorrhea and hoarseness are generally absent.[drplace.com]
  • […] infection Streptococcal sore throat (pharyngitis) Typical symptoms include of streptococcal sore throat include: a sore, red throat with thick pus-like fluid around the tonsils fever and chills enlarged and tender lymph nodes in and around the neck vomiting[betterhealth.vic.gov.au]
Abdominal Pain
  • Penicillin was shown to reduce fever and relieve sore throat, dysphagia, headache, abdominal pain, lethargy and anorexia significantly beyond that achieved with aspirin or acetaminophen alone. Penicillin had no effect on culture-negative cases.[ncbi.nlm.nih.gov]
  • Using data from all 453 patients, the groups did not differ for adverse effects, lymph node tenderness, abdominal pain, or recurrence.[acpjc.acponline.org]
  • In older children several nonspecific signs and symptoms can be associated with the disease, including headache, nausea, abdominal pain, malaise and vomiting (especially in older children).[news-medical.net]
  • Strep symptoms include sore throat, fever, ear pain, abdominal pain, and headache. There may be swollen and perhaps tender lymph nodes in the neck, bright red tonsils, and dark red hemorrhagic petechiae on the soft palate and uvula.[drhull.com]
  • Abdominal pain, nausea and vomiting may occur, although these symptoms are more characteristic of GABHS infection in children than in adults. Headache may be present, but cough, rhinorrhea and hoarseness are generally absent.[drplace.com]
Nausea
  • Leukopenia and nausea, the most common side effects observed, were more common in the cefprozil-treated group.[ncbi.nlm.nih.gov]
  • The beta-hemolytic streptococcus produces several poisons (toxins) which cause debility and nausea.[littledotapp.com]
  • In older children several nonspecific signs and symptoms can be associated with the disease, including headache, nausea, abdominal pain, malaise and vomiting (especially in older children).[news-medical.net]
  • Abdominal pain, nausea and vomiting may occur, although these symptoms are more characteristic of GABHS infection in children than in adults. Headache may be present, but cough, rhinorrhea and hoarseness are generally absent.[drplace.com]
  • Typical symptoms include fever (usually greater than 101.3 F), red throat, sore throat, headache, stomach ache, nausea, chills, malaise, loss of appetite, abnormal taste, swollen lymph nodes in the neck, and difficulty swallowing.[3,5] While a sore throat[austincc.edu]
Odynophagia
  • Management: Acute Episode Sore Throat symptomatic management Prescribe medications in liquid form if odynophagia Antibiotic Course Penicillin use requires 10 day course Five days of alternative antibiotics effective Amoxicillin Clavulanate ( Augmentin[fpnotebook.com]
  • Clinical Features Group A strep pharyngitis is an acute pharyngitis that commonly presents with Sudden-onset of sore throat Odynophagia Fever Figure 1. Streptococcus pyogenes (group A Streptococcus ) on Gram stain.[cdc.gov]
  • ., sudden onset of sore throat, fever, odynophagia, tonsillar erythema, exudates, cervical lymphadenitis, or history of streptococcal exposure) History and physical examination to establish risk Diagnostic testing RADT with Centor score of 2 or 3 only[aafp.org]
  • Dysphagia, odynophagia, and respiratory embarrassment are more variable than when the disease is caused by other pathogens. 71,73,74 Patients with GABHS supraglottitis tend to have involvement of the epiglottis.[ahcmedia.com]
Strawberry Tongue
  • Pus on the tonsils was less common and strawberry tongue more common in patients with eruptions than in those without. Skin eruptions were much more common in the patients infected with T4 than with other T types (p 0.001).[ncbi.nlm.nih.gov]
  • Tonsils (if present) are usually enlarged and erythematous with patchy exudates on their surfaces, while the tongue is red and swollen (often designated “strawberry tongue” for that reason). Lymph nodes of the neck can be enlarged and tender.[news-medical.net]
  • The rash may feel like sandpaper when touched a bright red tongue (known as ‘strawberry tongue’) paleness around the mouth. Impetigo blisters, typically around the nose and mouth and the legs fever and swollen lymph nodes in severe cases.[betterhealth.vic.gov.au]
  • There is circum- oral pallor and a strawberry tongue. There may be Pasita lines (petechiae) in the antecubital fossa area. May be accentuated in the underpants area. Can be pruritic and will often peel at the end of the illness.[pedclerk.bsd.uchicago.edu]
  • A strawberry tongue (inflamed papillae protruding through a bright red coating) also occurs and must be differentiated from that seen in toxic shock syndrome and Kawasaki disease.[merckmanuals.com]
Tonsillar Exudate
  • Physical examination may reveal erythema and swelling of the pharynx, enlarged and erythematous tonsils, tonsillar exudate and palatal petechiae.[drplace.com]
  • A culture positive case of streptococcal pharyngitis with typical tonsillar exudate in an 8-year-old.[en.wikipedia.org]
  • Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 F (38 C), tonsillar exudates, and cervical adenopathy. Cough, coryza, and diarrhea are more common with viral pharyngitis.[aafp.org]
  • About 20% of patients present with sore throat, fever, a beefy red pharynx, and a purulent tonsillar exudate. The remainder have less prominent symptoms, and the examination resembles that of viral pharyngitis.[merckmanuals.com]
  • Physical findings suggestive of GABHS infection include pharyngeal erythema, tonsillar exudates or petechial lesions on the palate. 63-65 A number of oral antibiotic agents may be prescribed to ameliorate the symptoms of GABHS pharyngitis ( see Table[ahcmedia.com]
Palatal Petechiae
  • Physical examination may reveal erythema and swelling of the pharynx, enlarged and erythematous tonsils, tonsillar exudate and palatal petechiae.[drplace.com]
  • On clinical examination, patients with group A strep pharyngitis usually have Pharyngeal and tonsillar erythema Tonsillar hypertrophy with or without exudates Palatal petechiae Anterior cervical lymphadenopathy Patients with group A strep pharyngitis[cdc.gov]
  • petechiae, the latter being an uncommon but highly specific finding. [9] Symptoms typically begin one to three days after exposure and last seven to ten days. [3] [9] Strep throat is unlikely when any of the symptoms of red eyes, hoarseness, runny nose[en.wikipedia.org]
  • Palatal petechiae and scarlatiniform rash are highly specific but uncommon; a swollen uvula is sometimes noted. Cough, coryza, conjunctivitis, and diarrhea are more common with viral pharyngitis.[aafp.org]
Exudative Pharyngitis
  • The triad of fever, pharyngeal exudate and anterior cervical adenopathy is present in only 15 percent of cases.[7] Exudate occurs in fewer than 50 percent of patients with GABHS pharyngitis; culture of an exudative pharyngitis leads to a diagnosis of[drplace.com]
Exudative Pharyngitis
  • The triad of fever, pharyngeal exudate and anterior cervical adenopathy is present in only 15 percent of cases.[7] Exudate occurs in fewer than 50 percent of patients with GABHS pharyngitis; culture of an exudative pharyngitis leads to a diagnosis of[drplace.com]
Flushing
  • Scarlet fever is caused by group A streptococcal strains that produce an erythrogenic toxin, leading to a diffuse pink-red cutaneous flush that blanches with pressure.[merckmanuals.com]
Hyperpigmentation
  • The rash of scarlet fever, which is characterized by a fine, blanching appearance, sandpaper texture, circumoral pallor and hyperpigmentation in the skin creases, is highly suggestive of GABHS infection.[drplace.com]
Circumoral Pallor
  • The rash of scarlet fever, which is characterized by a fine, blanching appearance, sandpaper texture, circumoral pallor and hyperpigmentation in the skin creases, is highly suggestive of GABHS infection.[drplace.com]
  • The rash is seen best on the abdomen or lateral chest and as dark red lines in skinfolds (Pastia lines) or as circumoral pallor.[merckmanuals.com]
  • The exanthem spares the mouth creating circumoral pallor. The rash is finely papular with a texture of coarse sandpaper.[ahcmedia.com]
  • S carlet Fever: Scarlet fever is characterized by high fever, circumoral pallor and a diffuse erythematous rash over the neck, trunk, face and limbs. There is a sandpaper consistency to the rash which blanches with pressure.[antimicrobe.org]
Headache
  • Penicillin was shown to reduce fever and relieve sore throat, dysphagia, headache, abdominal pain, lethargy and anorexia significantly beyond that achieved with aspirin or acetaminophen alone. Penicillin had no effect on culture-negative cases.[ncbi.nlm.nih.gov]
  • Major end points were sore throat, pharyngeal erythema or exudate, lymph node tenderness, fever, abdominal pain, headache, drug side effects, and bacteriologic cure.[acpjc.acponline.org]
  • Hepatitis Chronic Obstructive Pulmonary Disease Chronic Pancreatitis Chronic Pelvic Pain Syndrome (in men) Chronic Prostatitis Cigarette Addiction Cigarette Smokers, Nutrition Cirrhosis of the Liver Classic Migraine Climacteric Clinical Depression Cluster Headache[therapy.epnet.com]
  • In older children several nonspecific signs and symptoms can be associated with the disease, including headache, nausea, abdominal pain, malaise and vomiting (especially in older children).[news-medical.net]

Workup

  • "Cost-effective workup for tonsillitis. Testing, treatment, and potential complications". Postgrad Med. 113 (3): 115–8, 121. doi : 10.3810/pgm.2003.03.1391.[en.wikipedia.org]
  • ., positive identification of the infecting bacteria is necessary to separate out other bacteria that may cause some similar symptoms but may require a different workup, different treatment, and produce different complications.[medicinenet.com]
Positive Throat Culture
  • Twelve demographic and clinical features of patients with positive throat cultures were compared with the features of patients with negative throat cultures.[ncbi.nlm.nih.gov]
  • Furthermore, the physician made a subjective probability estimate for a GABHS-positive throat culture result (11-point scale: 0 most unlikely and 10 extremely likely).[acpjc.org]
  • Unfortunately, the study fails to make clear which patients, if any, with positive throat cultures after treatment were symptomatic.[acpjc.acponline.org]
  • Also, are patients that have persistent positive throat cultures following adequate treatment with antibiotics. The patient is clinically well. These patients are not contagious and are not at increased risk for Acute Rheumatic Fever.[pedclerk.bsd.uchicago.edu]
Positive Throat Culture
  • Twelve demographic and clinical features of patients with positive throat cultures were compared with the features of patients with negative throat cultures.[ncbi.nlm.nih.gov]
  • Furthermore, the physician made a subjective probability estimate for a GABHS-positive throat culture result (11-point scale: 0 most unlikely and 10 extremely likely).[acpjc.org]
  • Unfortunately, the study fails to make clear which patients, if any, with positive throat cultures after treatment were symptomatic.[acpjc.acponline.org]
  • Also, are patients that have persistent positive throat cultures following adequate treatment with antibiotics. The patient is clinically well. These patients are not contagious and are not at increased risk for Acute Rheumatic Fever.[pedclerk.bsd.uchicago.edu]
Gram-Positive Coccus
  • Crowding increases transmission as evidenced by common outbreaks in institutional settings, the military, school, etc.[5] Reservoirs: The human throat and skin are the reservoirs for S. pyogenes .[2] Specific Microbial Characteristics: S. pyogenes is a gram-positive[austincc.edu]
  • Wilde, MD, FAAP, Associate Professor, Emergency Medicine and Pediatrics, Section Chief, Pediatric Emergency Medicine, Medical College of Georgia, Augusta, GA Streptococcus pyogenes is an aerobic, gram-positive coccus, forming either short or long chains[ahcmedia.com]
  • G ENERAL DESCRIPTION M icrobiology Streptococcus pyogenes, or Group A streptococcus (GAS), is a facultative, Gram-positive coccus which grows in chains and causes numerous infections in humans including pharyngitis, tonsillitis, scarlet fever, cellulitis[antimicrobe.org]
Gram-Positive Bacteria
  • Group A beta-hemolytic streptococci (GABHS) are gram-positive bacteria that grow in culture as pairs or chains of variable length.[pedsinreview.aappublications.org]
  • However, S. dysgalactiae can also be group A. [1] S. pyogenes is a beta-hemolytic species of Gram positive bacteria that is responsible for a wide range of both invasive and noninvasive infections. [2] Infection of GAS may spread through direct contact[en.wikipedia.org]
  • Mupirocin is effective against gram-positive bacteria, especially methicillin-sensitive Staphylococcus aureus (MSSA) and GABHS.[ahcmedia.com]

Treatment

  • Delay in penicillin treatment did not increase GABHS intrafamilial spread. Symptoms of both groups were assessed for 2 days following the initiation of treatment.[ncbi.nlm.nih.gov]
  • Clarithromycin vs penicillin in the treatment of streptococcal pharyngitis. J Fam Pract. 1992 Dec;35:622-6.[acpjc.acponline.org]

Prognosis

  • What is the prognosis for group A streptococcal infections? The prognosis for mild GAS infections is usually good to excellent.[medicinenet.com]
  • The Infectious Diseases Society of America guidelines and Red Book address determining someone if is a carrier and their management. 1, 2 Prognosis and Complications Rarely, suppurative and nonsuppurative complications can occur after group A strep pharyngitis[cdc.gov]
  • […] allergies [9] and some evidence supports cephalosporins as superior to penicillin. [31] [32] Streptococcal infections may also lead to acute glomerulonephritis ; however, the incidence of this side effect is not reduced by the use of antibiotics. [12] Prognosis[en.wikipedia.org]
  • Long-term prognosis is generally thought to be excellent, but some studies found that up to 20% of patients develop urinary abnormalities ( 13 ).[antimicrobe.org]

Etiology

  • Related Editorial Bacteria are responsible for approximately 5 to 10 percent of pharyngitis cases, with group A beta-hemolytic streptococci being the most common bacterial etiology.[aafp.org]
  • Most children and adolescents who develop a sore throat do not have GABHS as the cause; their infection is viral in etiology.[ncbi.nlm.nih.gov]
  • Acute Pharyngitis: Etiology and Diagnosis Schwartz B et al. Pharyngitis - Principles of Judicious Use of Antimicrobial Agents. Pediatrics. 1998; 101(1 Suppl.):171-174.[pedclerk.bsd.uchicago.edu]
  • Etiology: Streptococcus Pyogenes V. Symptoms Stretococcal exposure in last 2 weeks ( Test Sensitivity 19%, Test Specificity 91%) Pharyngitis Fever ( Temperature 100.9) Cough absent Headache Myalgia VII.[fpnotebook.com]
  • Therefore etiologic diagnosis should be pursued in order to initiate timely antibiotic therapy.[news-medical.net]

Epidemiology

  • PATIENTS AND METHODS: Residents of Rochester, Minn (age, 4-15 years), who had 3 or more GABHS pharyngitis episodes In 1 year, at least 1 month apart, between January 1, 1996, and December 31, 1998, were Identified using the resources of the Rochester Epidemiology[ncbi.nlm.nih.gov]
  • 130 Clarithromycin 132 Azithromycin 133 Flurithromycin 135 Telithromycin 136 Conclusion 137 Mechanisms of Antibiotic Resistance in Streptococcus pyogenes 143 Mechanisms of Macrolides Resistance in Streptococcus pyogenes 144 Efflux System 146 Molecular Epidemiology[books.google.com]
  • Epidemiological analysis of group A streptococci recovered from patients in China. J Med Microbiol 2006;55:1101-7. [Table 1], [Table 2][jlponline.org]
  • Modes of transmission, age distribution of cases, and other epidemiologic features are similar to those for streptococcal pharyngitis.[emedicine.medscape.com]
  • GABHS pharyngitis, acute rheumatic fever may develop in up to 3 percent of untreated patients; in endemic infections, fewer cases probably occur.[13] While the pathogenetic mechanisms responsible for the development of acute rheumatic fever are unclear, epidemiologic[drplace.com]
Sex distribution
Age distribution

Pathophysiology

  • Recent interest in the pathophysiology of this disorder has focused on the role of streptococcal pyrogenic exotoxins (SPEs), extracellular products of group A streptococci that mediate not only scarlatiniform-like rashes but also multi-organ damage and[antimicrobe.org]

Prevention

  • Antibacterial therapy is appropriate for GAS pharyngitis and may help prevent complications.[ncbi.nlm.nih.gov]
  • 167 Hypothetical Cohorts and MetaAnalysis 168 Prospective Study in France 169 CostEffectiveness of Antibiotic Therapy for Sore Throat 170 Third World 171 General Conclusion 172 Practical Problems Associated with the Prevention of Initial and Recurrent[books.google.com]
  • Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals.[aafp.org]
  • Commentary Pharyngitis caused by group A β-hemolytic streptococci is treated to prevent rheumatic fever and suppurative complications such as sinusitis and otitis media.[acpjc.acponline.org]

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