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Streptococcal Pharyngitis

Strep Throat

Streptococcal pharyngitis is the most common bacterial throat infection encountered in general practice. It is predominantly seen in younger children and adolescents, with typical manifestations of a sore throat, fever, enlarged tonsils with an exudate, and sometimes petechiae in the oral cavity. The initial diagnosis can be made based on findings obtained during history taking and the physical examination. To discriminate streptococcal pharyngitis from viral pharyngitis that is a very common disease, rapid antigen detection testing and throat cultures (if necessary) are used for a confirmation.


Presentation

Streptococcal pharyngitis is one of the most common diseases affecting the oral cavity, being responsible for up to 37% of throat infections in children over 5 years of age [1]. The responsible pathogen is group A beta-hemolytic Streptococcus. The clinical presentation of streptococcal pharyngitis starts after a small incubation period of 2-5 days and after being previously exposed to streptococci through respiratory secretions of infective individuals [1] [2]. Regardless of the etiology, throat infections commonly present with a sudden onset of a sore throat, fever of > 38° C, chills, headaches, myalgias, and possibly gastrointestinal complaints [1] [2] [3] [4]. Signs that are highly suggestive of streptococcal pharyngitis are the presence of cervical lymphadenopathy and tonsillar enlargement with the production of a yellow exudate [2] [3] [4]. Scarlatiniform rash and palatal petechiae are very specific but are rarely seen in streptococcal pharyngitis [1] [2] [3] [4]. If upper respiratory tract signs such as a cough, coryza, or conjunctivitis, accompany constitutional and throat-related symptoms, it is highly likely that the infection is of viral origin [1] [2] [3] [4].

Generalized Lymphadenopathy
  • ., generalized lymphadenopathy and splenomegaly). Systemic infections with cytomegalovirus, rubella virus, measles virus, and a number of other viral agents may be associated with acute pharyngitis.[dx.doi.org]
Streptococcal Pharyngitis
  • Streptococcal pharyngitis is the most common bacterial throat infection encountered in general practice.[symptoma.com]
  • Table 4 Recommendations for antimicrobial therapy for group A streptococcal pharyngitis. Table 4 Recommendations for antimicrobial therapy for group A streptococcal pharyngitis.[dx.doi.org]
  • […] glomerulonephritis are the nonsuppurative complications of streptococcal pharyngitis.[web.archive.org]
  • Stillerman M (1970) Comparison of cephaloglycin and penicillin in streptococcal pharyngitis. Clin Pharmacol Ther 11:205–213 PubMed Google Scholar 31.[oadoi.org]
Cerebral Palsy
  • Ocular and oropharyngeal cultures from a 24-month-old child with a history of cerebral palsy on BiPAP at night revealed the same strain of Streptococcus pyogenes.[ncbi.nlm.nih.gov]
Chest Discomfort
  • Advances in rapid bedside testing for both myocardial injury and GAS pharyngitis have allowed for increasing recognition of this uncommon complication in patients presenting with a sore throat with associated chest discomfort.[ncbi.nlm.nih.gov]
Nausea
  • A headache, and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever.[en.wikipedia.org]
  • […] usually starts quickly and can cause severe pain when swallowing A fever (101 F or above) Red and swollen tonsils, sometimes with white patches or streaks of pus Tiny, red spots (petechiae) on the roof of the mouth (the soft or hard palate) Headache, nausea[web.archive.org]
  • […] on quickly Painful swallowing Red and swollen tonsils, sometimes with white patches or streaks of pus Tiny red spots on the area at the back of the roof of the mouth (soft or hard palate) Swollen, tender lymph nodes in your neck Fever Headache Rash Nausea[mayoclinic.com]
  • […] suddenly and is often the highest on the second day Chills Red, sore throat that may have white patches Pain when swallowing Swollen, tender neck glands Other symptoms may include: General ill feeling A loss of appetite and abnormal sense of taste Headache Nausea[medlineplus.gov]
Abdominal Pain
  • BACKGROUND: Several pathologies, including pharyngitis, are associated with abdominal pain that can mimic appendicitis. We sought to further understand the link between appendicitis-like symptoms and streptococcal (strep) pharyngitis.[ncbi.nlm.nih.gov]
  • The typical signs and symptoms of streptococcal pharyngitis are a sore throat, fever of greater than 38 C (100 F), tonsillar exudates (pus on the tonsils), and large cervical lymph nodes.Other symptoms include: headache, nausea and vomiting, abdominal[en.wikipedia.org]
  • Children, for example, may present with abdominal pain or emesis.[web.archive.org]
  • pain, vomiting, diarrhea, presence of anterior cervical lymph nodes, size of the nodes ( 1, 1–2 or 2 cm), tenderness of the nodes, skin rash, and aspect of the rash (scarlatiniform or nonspecific).[doi.org]
Thrombosis
  • […] pharyingitis include non-suppurative complications such as acute rheumatic fever and glomerulonephritis and suppurative complications such as peritonsillar or retropharyngeal abscess, sinusitis, mastoiditis, otitis media, meningitis, brain abscess, or thrombosis[ncbi.nlm.nih.gov]
Aphthous Ulceration
  • With regards to chronic pharyngitis, non-infectious etiologies, such as laryngopharyngeal reflux and periodic fever, aphthous ulcers, pharyngitis, and adenitis syndrome also need to be considered.[ncbi.nlm.nih.gov]
Diplopia
  • We described a case of a 15-year-old patient with a history of acute pharyngodinia early followed by improvise fever and a progressive formation of a diffuse orbital edema, corneal hyperaemia, diplopia and severe decrease of visual acuity.The patient[ncbi.nlm.nih.gov]
Anterior Uveitis
  • RESULTS: An adolescent girl in whom anterior uveitis was the only manifestation of poststreptococcal syndrome subsequently developed recurrent anterior uveitis after another episode of streptococcal pharyngitis.[ncbi.nlm.nih.gov]
Excoriation
  • Other findings may include a beefy, red, swollen uvula; petechiae on the palate; excoriated nares (especially in infants); and a scarlatiniform rash. However, none of these findings is specific for group A β-hemolytic streptococcal pharyngitis.[dx.doi.org]
Headache
  • Along with the sudden onset of throat pain, GAS pharyngitis symptoms include fever, headache, and bilateral tender cervical lymphadenopathy (1,2).[ncbi.nlm.nih.gov]
  • Regardless of the etiology, throat infections commonly present with a sudden onset of a sore throat, fever of 38 C, chills, headaches, myalgias, and possibly gastrointestinal complaints.[symptoma.com]
  • A headache, and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever.[en.wikipedia.org]
  • […] throat, usually starts quickly and can cause severe pain when swallowing A fever (101 F or above) Red and swollen tonsils, sometimes with white patches or streaks of pus Tiny, red spots (petechiae) on the roof of the mouth (the soft or hard palate) Headache[web.archive.org]
  • […] usually comes on quickly Painful swallowing Red and swollen tonsils, sometimes with white patches or streaks of pus Tiny red spots on the area at the back of the roof of the mouth (soft or hard palate) Swollen, tender lymph nodes in your neck Fever Headache[mayoclinic.com]
Tonic-Clonic Seizure
  • A few hours after admission, the patient had sudden onset of two witnessed tonic-clonic seizures and subsequent decreased mental status. She was transferred to the paediatric intensive care unit and started on broad-spectrum antibiotics.[ncbi.nlm.nih.gov]

Workup

The diagnosis of streptococcal pharyngitis rests on a thorough clinical assessment and appropriate microbiological studies. Firstly, the physician should obtain a comprehensive patient history that will determine the onset of symptoms, their duration, as well as recent exposure to other individuals with similar complaints. The physical examination, on the other hand, is sufficient to make a presumptive diagnosis through recognizing inflammatory changes in the throat. In addition to clinical findings, younger age (children over 3 years of age and adolescents) must be taken into account as a risk factor that will promote testing [5].

Rapid antigen detection testing (RADT) on previously obtained throat swabs is described as the first and most important study for detecting streptococci in the throat, as it provides results within minutes and carries very high sensitivity rates [1] [2] [5] [6] [7]. If RADT is negative, but the signs and symptoms strongly point toward a bacterial cause, throat cultures should be performed in order to make a definitive diagnosis [1] [2] [4] [5] [8]. The test requires approximately 18-24 hours to show a significant growth of bacteria [1].

Although serological tests for streptococcal antibodies (antistreptolysin-O titers) exist in clinical practice, they are not routinely used because of their delayed appearance in the case of streptococcal pharyngitis (up to several weeks) [2] [4]. Their measurement is indicated when either rheumatic fever or poststreptococcal glomerulonephritis is suspected [2]. However, they may be useful for discriminating between an acute infection and a chronic carrier state [2] [4].

Atrioventricular Dissociation
  • The initial electrocardiogram showed junctional tachycardia with atrioventricular dissociation in addition to prolonged and aberrant atrioventricular conduction. An echocardiogram revealed normal cardiac anatomy with normal biventricular function.[ncbi.nlm.nih.gov]

Treatment

  • Both treatments were well tolerated; and most adverse events (AEs) were mild to moderate in intensity. The most frequent treatment-related AE was diarrhoea, or loose stools, in 11% of both treatment groups.[ncbi.nlm.nih.gov]
  • For the comparison of 10 days of treatment with cephalosporins versus 10 days of treatment with penicillin, there were ten European and 25 U.S. trials, all involving pediatric subjects.[oadoi.org]
  • Alternative treatments must be used in patients with penicillin allergy, compliance issues or penicillin treatment failure.[web.archive.org]

Prognosis

  • Prognosis GABHS pharyngitis is usually a self-limited illness. Throat symptoms resolve within 3-4 days in untreated patients.[emedicine.com]
  • Relation of bed rest and activity to prognosis. Postgrad Med 1964;35:345-9. 22. Torre D, Tambini R. Acyclovir for treatment of infectious mononucleosis: a meta-analysis. Scand J Infect Dis 1999;31:543-7. 23.[web.archive.org]
  • Relation of bed rest and activity to prognosis. Postgrad Med. 1964;35:345–9. 22. Torre D, Tambini R. Acyclovir for treatment of infectious mononucleosis: a meta-analysis. Scand J Infect Dis. 1999;31:543–7. 23.[aafp.org]

Etiology

Epidemiology

  • Table 3 Clinical and epidemiological findings and diagnosis of pharyngitis due to group A β-hemolytic streptococci (GABS). Table 3 Clinical and epidemiological findings and diagnosis of pharyngitis due to group A β-hemolytic streptococci (GABS).[dx.doi.org]
  • Author information 1 INSERM, UMR S953, Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, Paris, France. jeremie.cohen@inserm.fr Abstract We investigated mechanisms of the false-positive test results on rapid-antigen[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • While the natural history of carditis complicating acute rheumatic fever is well established, the incidence, pathophysiology and clinical course of nonrheumatic myopericarditis are ill defined.[ncbi.nlm.nih.gov]
  • Pathophysiology Beta-hemolytic streptococci have the ability to cause large zones of hemolysis on blood agar, aiding in microbiological identification. [2] Lancefield antigens, carbohydrates in the cell wall, provide further differentiation of streptococci[emedicine.com]
  • […] physicians should expect to diagnose one to four patients with infectious mononucleosis per year, depending on the number of adolescents in their practice. 3,5 The incidence of infectious mononucleosis shows no consistent seasonal peak. 2 Etiology and Pathophysiology[web.archive.org]

Prevention

  • There is no vaccine to prevent strep throat.[web.archive.org]
  • Data were analysed separately for general practice and the school programmes for rheumatic fever prevention.[ncbi.nlm.nih.gov]
  • Prevention To prevent strep infection: Clean your hands. Proper hand cleaning is the best way to prevent all kinds of infections.[mayoclinic.com]

References

Article

  1. Regoli M, Chiappini E, Bonsignori F, Galli L, de Martino M. Update on the management of acute pharyngitis in children. Ital J Pediatr. 2011;37:10.
  2. Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79(5):383-390.
  3. Lieberman D, Shvartzman P, Korsonsky I, Lieberman D. Aetiology of respiratory tract infections: clinical assessment versus serological tests. Br J Gen Pract. 2001;51(473):998–1000.
  4. Anjos LM, Marcondes MB, Lima MF, Mondelli AL, Okoshi MP. Streptococcal acute pharyngitis. Rev Soc Bras Med Trop. 2014;47(4):409-413.
  5. McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ: Canadian Medical Association Journal. 1998;158(1):75-83.
  6. Ezike EN, Rongkavilit C, Fairfax MR, Thomas RL, Asmar BI. Effect of using 2 throat swabs vs 1 throat swab on detection of group A streptococcus by a rapid antigen detection test. Arch Pediatr Adolesc Med. 2005;159(5):486–490.
  7. Neuner JM, Hamel MB, Phillips RS, Bona K, Aronson MD. Diagnosis and management of adults with pharyngitis. A cost-effectiveness analysis. Ann Intern Med. 2003;139(2)113–122.
  8. Pelucchi C, Grigoryan L, Galeone C, et al. Guideline for the management of acute sore throat. ESCMID Sore Throat Guideline Group. Clin Microbiol Infect. 2012; 18 (suppl 1):1-28.

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Last updated: 2019-07-11 20:30