Streptococcal pharyngitis

Background

• Peak in 5-15yr old
• Rare in <2yr of age
• Accounts for only 15-30% of pharyngitis

Clinical Features

culture positive strep pharyngitis with typical tonsillar exudate

• Sore throat
• Painful swallowing
• Fever
• Nausea and vomiting
• Tonsillar exudate
• Palatal petechiae

Complications

• Acute rheumatic fever
• Scarlet fever
• Toxic shock syndrome
• Post-streptococcal glomerular nephritis
• PANDAS syndrome
• Peritonsillar abscess
• Cervical lymphadenitis
• Mastoiditis

Differential Diagnosis

Acute Sore Throat

Bacterial infections

• Streptococcal pharyngitis (Strep Throat)
• Neisseria gonorrhoeae
• Diphtheria (C. diptheriae)
• Bacterial Tracheitis

Viral infections

• Infectious mononucleosis (EBV)
  • Patients with peritonsillar abscess have a 20% incidence of mononucleosis
• Laryngitis
• Acute Bronchitis
• Rhinovirus
• Coronavirus
• Adenovirus
• Herpesvirus
• Influenza virus
• Coxsackie virus
  • Herpangina
  • Hand-foot-and-mouth disease
• HIV (Acute Retroviral Syndrome)

Noninfectious

• Stevens-Johnson Syndrome
• Pemphigus
• Angioedema

Other

• Deep neck space infection
  • Retropharyngeal abscess
  • Ludwig's angina
  • Parapharyngeal space infection
• Peritonsillar Abscess (PTA)
• Epiglottitis
• Kawasaki disease
• Penetrating injury
• Caustic ingestion
• Lemierre's syndrome
• Peritonsillar cellulitis
• Lymphoma
• Internal carotid artery aneurysm
• Oral Thrush
• Parotitis
• Post-tonsillectomy hemorrhage
• Vincent's angina
• Acute necrotizing ulcerative gingivitis

Oral rashes and lesions

• Angioedema
• Aphthous stomatitis
• Herpes gingivostomatitis
• Herpes labialis
• Measles (Koplik's spots)
• Perioral dermatitis
• Oral thrush
• Steven Johnson syndrome
• Streptococcal pharyngitis
• Tongue diagnoses
• Vincent's angina

Diagnosis

Modified Centor Criteria

One point is given for each of the criteria:

• Absence of a cough
• Swollen and tender cervical lymph nodes
• Temperature >38.0 °C (100.4 °F)
• Tonsillar exudate or swelling
• Age less than 15 (a point is subtracted if age >44)^

Modified Centor score

Points	Probability of Strep	Management
1 or fewer	<10%	No antibiotic or culture needed
2	11–17%	Antibiotic based on rapid strep or culture
3	28–35%
4 or 5	52%	Empiric antibiotics

^Testing is not needed in children <3 years old as both group A strep and rheumatic fever are rare, except if they have a sibling with the disease.

Management

Antibiotics

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:

• Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)
• Bicillin L-A <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1
• Amoxicillin 50 mg/kg once daily (maximum = 1000 mg) for 10 days

Penicillin allergic (mild):

• Cephalexin 20 mg per kg PO BID (maximum 500 mg per dose) x 10 days
• Cefadroxil 30 mg per kg PO QD (maximum 1 g daily) x 10 days

Penicillin allergic (anaphylaxis):

• Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days
• Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days
• Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days

Steroids

• Single dose of dexamethasone shortens duration of pain
  • Dexamethasone 0.6mg/kg PO - maximum of 10 mg

Disposition

• Discharge

See Also

• Sore Throat