Strep_throat

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Strep Throat Classification & external resources
Strep Throat
ICD-10	J02.0
ICD-9	034.0

Strep throat (AE),or streptococcal sore throat is a form of group A streptococcal infection that affects the pharynx and possibly the larynx and tonsils.

Contents 1 Symptoms 2 Diagnosis 2.1 Signs and symptoms 2.2 Tests 3 Transmission 4 Treatment 5 Complications 5.1 Infectious complications 5.2 Noninfective complications 6 See also 7 References 8 External links

Symptoms

• Sudden and severe sore throat
• Abdominal pain
• Yellow and white patches in the throat.
• Difficulty swallowing
• Tender cervical lymphadenopathy
• Red and enlarged tonsils
• Halitosis
• Fever of 38°C (101°F) or greater.
• RashKids Health
• Frequent cold chills
• Absence of cough or dry cough
• White spots on tonsils
• Peeling skin on fingertips a few weeks after treatment
• Hives or other systemic allergic response, without the presence of the symptoms listed above

Diagnosis

Signs and symptoms

A study of 729 patients with pharyngitis in which 17% had a positive throat culture for group A streptococcus, identified the following four best predictors of streptococcus:Centor RM, Dalton HP, Campbell MS, Lynch MR, Watlington AT, Garner BK. Rapid diagnosis of streptococcal pharyngitis in adult emergency room patients. J Gen Intern Med. 1986 Jul-Aug;1(4):248-51. PMID 3534175

1. Lack of cough

• sensitivity = 56%
• specificity = 74%

2. Swollen and tender anterior cervical lymph nodes

3. (Marked) tonsillar exudates. Although the original study did not specify the degree of exudate, \'marked exudate\' may be more accurate. A subsequent study of 693 patients with 9.7% having positive cultures found that \'marked exudates\' had a sensitivity and specificity of 21% and 70% while \'pinpoint exudates\' were nonspecific with sensitivity and specificity of 22% and 45%.Komaroff AL, Pass TM, Aronson MD, et al (1986). "The prediction of streptococcal pharyngitis in adults". J Gen Intern Med 1 (1): 1–7. PMID 3534166. 

• sensitivity = 65%
• specificity = 69%

4. History of fever

• sensitivity = 78%
• specificity = 45%

When these findings are counted in a patient, the probabilities of positive cultures in the original study (prevalence=17%) are:.

• 4 findings -> 55.7%
• 3 findings -> 30.1 – 34.1%
• 2 findings -> 14.1 – 16.6%
• 1 findings -> 6.0 - 6.9%
• 0 findings -> 2.5%

The probabilities can also be computed with the following equation:

$X\; =\; -2.69\backslash \; -0.95\backslash \; (if\backslash \; cough)\backslash \; +1\backslash \; (if\backslash \; swollen\backslash \; nodes)\backslash \; +1.04\backslash \; (if\backslash \; marked\backslash \; exudate)\backslash \; +0.89\backslash \; (if\backslash \; history\backslash \; fever)$

Strep throat usually appears suddenly with a severe sore throat. The throat is so sore that many people find it painful to talk or even swallow. In severe cases, breathing may be impaired. A fever may be present, though some people may only have a low-grade fever.

Productive coughing, nasal discharge, and red, irriated eyes in addition to fever and sore throat are more indicative of a viral sore throat than of strep throat, though a co-infection with a virus is possible and may explain the presence of these additional symptoms. A strep test or throat swap culture also red spots will appear on the back of tongue will settle the matter conclusively.

Tests

The throat of the patient is swabbed for culture or for a Rapid Strep Test (5 to 15 min), which can be done in the doctor\'s office. A rapid test tests for the presence of a carbohydrate antigen unique to Group A Streptococcus. If the rapid test is negative, a follow-up culture (which takes 24 to 48 hours) may be performed if all or most symptoms of strep throat are present. A negative culture could suggest a viral infection, in which case antibiotic treatment should be withheld or discontinued. A doctor may perform further examination as it still may be possible that the patient is suffering from a bacterial infection. It is possible to test too early, and testing can give a false negative.

Throat swab cultures are usually more accurate than the rapid strep test.

A full blood count blood test will show raised levels of neutrophil white blood cells in bacterial infection, but a raised lymphocyte count is more suggestive of a viral illness. Lymphocytes comprise on average 10% of the total white cells in bacterial tonsillits and 54% in glandular fever; a level above 35% has a specificity of 100% and a sensitivity of 90% for the detection of glandular fever.Wolf DM, Friedrichs I, Toma AG (2007). "Lymphocyte-white blood cell count ratio: a quickly available screening tool to differentiate acute purulent tonsillitis from glandular fever". Arch. Otolaryngol. Head Neck Surg. 133 (1): 61–4. doi:10.1001/archotol.133.1.61. PMID 17224526.  If the troat culture test is posiive befre 6 minutes then the victim is qute sick.

Transmission

Strep throat is caused by the bacterium Streptococcus pyogenes.Moran, C., Opdyke, J., & Scott, J. (2001). A secondary RNA polymerase sigma factor from streptococcus pyogenes. Molecular Microbiology, 42(2), 495-502. Retrieved December 4, 2007, from Academic Search Elite.Gieseker, K., MacKenzie, T., Roe, M., & Todd, J. (2003). Evaluating the American academy of pediatrics diagnostic standard for streptococcus pyogenes pharyngitis: Backup culture versus repeat rapid antigen testing. Pediatrics, 111(6), 666-670. Retrieved December 4, 2007, from Academic Search Elite.Bakshi, D.K., Chakraborti, A., Ganguly, N.K., Kumar, R., Nandi, S., & Rani, A. (2002). Association of pyrogenic exotoxin genes with pharyngitis and rheumatic fever/rheumatic heart disease among Indian isolates of streptococcus pyogenes. Applied Microbiology, 35, 237-241. Retrieved December 4, 2007, from Academic Search Elite.Allerberger, F., Brandt, C., Haase, G., Holland, R., Lutticken, R., Spellerberg, B. (2001). Characterization of consecutive streptococcus pyogenes isolates from patients with pharyngitis and bacteriological treatment failure: Special reference to prtF1 and sic/drs. The Journal of Infectious Diseases, 183, 670-674. Retrieved December 4, 2007, from Academic Search Elite. It is spread by direct, close contact with an infected person via respiratory droplets. In one study, 114 patients with positive throat cultures and a presence of group A beta-hemolytic streptococci (GAS) were studied to see transmission within their families through pillow cases, toys, and patients tooth brush. Of those 114 patients studied 50 patients received hygiene instructions to follow and 64 were not given hygiene instructions. The percent of culture-verified recurrences was 35%.Falck, G., Kjellander, J., & Schwan, A. (1997). Recurrence rate of streptococcal pharyngitis related to hygienic measures. Scand J Prim Health Care, 16, 8-12. Retrieved December 4, 2007, from Academic Search Elite. Casual contact can result in transmission like the study that was done on transmission in households by two Norwegian health centers. 127 patients with positive throat cultures and their families were studied. Four weeks after the beginning of the study, other members of the household were asked if they had any positive throat culture since the beginning of the study; In 30 households there was one more case of infection, in 22 households 2 more cases, 6 households with 3 cases, and 2 households with 4 cases.Hjortdahl, P., Hoiby, E., Lermark, G., Lindbaek, M., & Steinsholt, M. (2004). Predictors for spread of clinical group A streptococcal tonsillitis within the household. Taylor & Francis Health Sciences, 22, 239-243. Retrieved November 30, 2007, from Academic Search Elite. Rarely, contaminated food, especially milk and milk products, can result in outbreaks. One study stated that a sandwich layer cake had been served at a party, and 2 days later, 4 family members who ate the cake fell ill with high temperatures, shivers, and sore throats, and the 2 family members who didn’t eat the cake were not infected. The cake had been served to at least 16 parties, and all individuals who attended parties where the cake was served were questioned. Of the 212 who had eaten the cake, 153 (72%) fell ill with sore throat, fever, and shivering.Andersson, Y., Asteberg, I., Darenberg, J., Dotevall, L., Ericsson, M., Henriques-Nordmark, B., & Soderstorm, A., A food-borne streptococcal sore throat outbreak in a small community. Scandinavian Journal of Infectious Diseases, 38, 988-994. Retrieved November 30, 2007, from Academic Search Elite.

The incubation period for strep throat is thought to be between two to five days. One outbreak’s incubation period was two to eight days. It began in a dormitory when 394 primary and secondary cases had positive throat cultures between May 20th and May 28th. Later it was found the outbreak started from 2 cooks who were positive for GAS also. 268 of a total of 943 students who ate the suspected food from May 18th became GAS positive.Farmarzi, H., Fatehmanesh, P., Javanian, M., Majdzadeh, R., Naderi, H.R., Naderi-Nassab, M., Sarvghad, M.R. (2005). An outbreak of food-borne group A streptococcus (GAS) tonsillopharyngitis among residents of a dormitory. Scandinavian Journal of Infectious Diseases, 37, 647-650. Retrieved December 6, 2007, from Academic Search Elite.

Strep is caused by a strain of bacteria of a type called group A beta-hemolytic streptococci.Jankowski, K., Kelsberg, G., & Merrill, B. (2004). What is the most effective diagnostic evaluation of streptococcal pharyngitis? The Journal of Family Medicine, 53(9), 734-740. Retrieved December 4, 2007, from Academic Search Elite.Centor, R., Dalton, H., & Meier, F. (1986). Throat cultures and rapid tests for diagnosis of group A streptococcal pharyngitis. Annals of Internal Medicine, 105, 892-899. Retrieved December 4, 2007, from Academic Search Elite.Falck, G., Kjellander, J., & Schwan, A. (1997). Recurrence rate of streptococcal pharyngitis related to hygienic measures. Scand J Prim Health Care, 16, 8-12. Retrieved December 4, 2007, from Academic Search Elite.Kieserman, S., & Williams, J. (1995). Streptococcal pharyngitis: Alternative treatments. Ear, Nose & Throat Journal, 74(11), 777-781. Retrieved December 4, 2007, from Academic Search Elite. Symptoms include: sore throat, fever, headache, and in some cases, chills, nausea, and vomiting. Family physicians took a “strep” score for 621 patients, where one point was assigned for each of the following symptoms: temperature greater than 38 C, absence of cough, tender anterior cervical adenopathy, tonsillar swelling or exudate, age younger than 15, and subtracting a point for age older than 45. A score of one or less was negative with no throat culture or antibiotic, a score of two or three was considered indeterminate with a throat culture and antibiotic based on throat culture, and a score of four or greater was positive with throat culture and antibiotics. The occurrence of strep was 17% score of two, 35% score of three, and 51% score of four or more.Goel, V., & McIsaac, W. (2000). The validity of a sore throat score in family practice. Canadian Medical Association Journal, 163(7), 811-816. Retrieved December 9, 2007, from Academic Search Elite. The patient usually experiences swelling of the tonsils and lymph nodes in the neck; swelling can also be located in the soft palate in the top of the mouth. Authors identified, reviewed, and pooled data of studies of the diagnosing of group A beta-hemolytic streptococcal pharyngitis in patients with a sore throat. The absence of tender anterior cervical lymph nodes, tonsillar enlargement, and tonsillar or pharyngeal exudates was most useful in ruling out strep throat with a negative likelihood of 0.74.Barry, Carey, Ebell, Ives, & Smith. What clinical features are useful in diagnosing strep throat? The Journal of Family Practice, 50, 201. Retrieved November 20, 2007, from Academic Search Elite.

Treatment

Treatment will reduce symptoms slightly, as was the case in one study of 11 adult patients with sore throat and confirmed GAS infection. They were evaluated daily after the start of antibiotic treatment to register symptoms and signs and to measure body temperature. The mean reduction rate was great, but it was the greatest reduction after 2 days. Out of all symptoms scores was for muscle or joint pain, 86%, and the lowest for sore throat, 67%.Bjorkheim, K., Leinan, T., & Melbye, H. (2002). Daily reduction in C-reactive protein values symptoms, signs and temperature in group-A streptococcal pharyngitis treated with antibiotics. Taylor & Francis Health Sciences, 62, 521-526. Retrieved December 5, 2007, from Academic Search Elite. Treatment, which consists of penicillin (orally for 10 days or a single intramuscular injection of penicillin G), will also minimize transmission which is why until children that are positive for GAS have taken 24 hours of antibiotic should not go back to school or day care. In one study, they assessed the potential risk of transmission to close school contact by taking 47 children with positive throat cultures and randomly selected them to receive penicillin V, penicillin G, or erythromycin. Throat culture were then taken 24 hours after start of antibiotics and 17 (36.2%) had positive throat cultures and 39 (83%) of the patients became culture negative.Johnson, D., Kaplan, E., Snellman, L., Stang, H., & Stang, M. (1993). Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics, 91(6), 1167-1170. Retrieved November 26, 2007, from Academic Search Elite.

Cephalosporins, such as cefazoline, cefuroxime, and ceftriaxone, are recommended for penicillin-allergic patients. In a study 41 patients, with confirmed penicillin allergy, were evaluated with cefazoline, cefuroxime, and ceftriaxone, all cephalosporins, to see the allergic reaction. Skin tests with cephalosporins were clearly negative in 39 patients and all 41 patients tolerated the three cephalosporins administered.Bombin, C., Cuesta, J., de las Heras, M., Lluch-Bernal, M., Quirce, S., & Novalbos, A. (2001). Lack of allergic cross-reactivity to cephalosporins among patients allergic to penicillins. Clinical and Experimental Allergy, 31, 438-443. Retrieved November 30, 2007, from Academic Search Elite. Second-line antibiotics include amoxicillin, clindamycin, and oral cephalosporins. 152 patients in a study all with positive throat cultures were randomly assigned to receive either penicillin orally 3 times a day for 10 days or amoxicillin orally once a day for 10 days. At the 18 to 24 hour follow-up 1 of the 73 patients taking penicillin had a positive throat culture and none of 79 patients taking amoxicillin.Feder, H., Gerber, M., Kaplan, E., Randolph, M., & Stelmach, P. (1999). Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics, 103(1), 47-51. Retrieved December 4, 2007, from Academic Search Elite. Throat cultures were performed on elementary schools children in Pittsburgh. Of those students 209 were treated with antibiotic and 5% were treated with clindamycin and there were no clinical treatment failures.Barbadora, K., Green, M., Martin, J., & Wald, E. (2004). Group A streptococci amon school-aged children: Clinical characteristics and the carrier state. Pediatrics, 114(5), 1212-1219. Retrieved December 6, 2007, from Academic Search Elite.

It is important to complete the full course of antibiotics to prevent rheumatic fever or an abscess on the tonsils. In one report of 500 patients 30% had group A beta-hemolytic streptococcal pharyngitis 0.2% had rheumatic fever and 0.2% had peritonsillar abscess (an abscess on the tonsils) (Ebell, 2004). Another complication that can occur is acute glomerulonephritis like in one study where 5318 children with positive throat cultures for GAS were randomly given either 10 days of penicillin or 5 days of amoxicillin, clarithromycin, or erythromycin. Out of all the children two got acute glomerulonephritis.Dieter, A., Helmerking, M., & Horst, S. (2000). Is a 5-day course of antibiotics as effective as a 10-day course for the treatment of streptococcal pharyngitis and the prevention of poststreptococcal sequelae? The Journal of Family Practice, 49(12), 1147. Retrieved December 6, 2007, from Academic Search Elite.

The overall summary odds ratio for the bacteriologic cure rate significantly favors cephalosporins compared with penicillin like in one study that compared penicillin and cephalosporin cure rates of GAS by taking 7125 patients in 35 trials with positive throat cultures and randomly administering cephalosporin or penicillin for a 10-day treatment. The primary outcome odds ratio of cure rate comparing the two was 3.02 v.s. 2.33, significantly favoring cephalosporin treatments.Casey, J., & Pichichero, M. (2004). Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics, 113(4), 866-882. Retrieved November 30, 2007, from Academic Search Elite.

The most common virus illness responsible for strep-like symptoms is glandular fever, also known as mononucleosis. In a study at least 98% of 500 patients with confirmed infectious mononucleosis had sore throat, lymph node enlargement, fever, and tonsillar enlargement. Symptoms that are similar to streptococcal pharyngitis (strep throat) symptoms.Ebell, M. (2004). Epstein-Barr virus infectious mononucleosis. American Family Physician, 70(7), 1279-1287. Retrieved December 6, 2007, from Academic Search Elite.

Other ways to relieve strep symptoms include taking nonprescription medications (ibuprofen and acetaminophen/paracetamol) for throat pain and fever reduction. A total of 200 pediatric patients with a mean temperature of 39.2˚C were studied and were randomly given an oral dose of ibuprofen or paracetamol. The reduction in temperature between both treatments didn’t differ, each had a mean decrease difference of 1.2˚C or 1.3˚C.Bayle, M., Calatayud, G., Campdera, A., Fernandez, J., Garcia de Miguel, M., & Nadal, C. (2002). Effectiveness and tolerability of ibuprofen-arginine versus paracetamol in children with fever of likely infectious origin. Acta Paediatr, 91, 383-390. Retrieved December 11, 2007, from Health Source: Nursing. A study in general practice with 8233 patients with musculoskeletal or back pain and sore throat were randomly given 7 days of aspirin, paracetamol, or ibuprofen. The overall pain reduction for musculoskeletal of back pain was 48% and 31% for sore throat.Farhan, M., Leparc, J.M., Moore, N., Pelen, F., Vanganse, E., Verriere, F., & Wall, R. (1999). The pain study: Paracetamol, aspirin and ibuprofen new tolerability study: A large-scale, randomized clinical trial comparing the tolerability of aspirin, ibuprofen and paracetamol for short-term analgesia. Clinical Dug Investigation, 18(2), 89-98. Retrieved on December 9, 2007.

A 2003 study found extract of Pelargonium sidoides was superior compared to placebo for the treatment of acute non-GABHS tonsillopharyngitis in children. Treatment with EPs 7630 reduced the severity of symptoms and shortened the duration of illness by at least 2 days.Bereznoy VV, Riley DS, Wassmer G, Heger M. (2003). Efficacy of extract of Pelargonium sidoides in children with acute non-group A beta-hemolytic streptococcus tonsillopharyngitis: a randomized, double-blind, placebo-controlled trial. Altern Ther Health Med. 2003 Sep-Oct;9(5):68-79. People who get strep throat should stay home for about a week or two, depending upon how bad they are sick

Complications

The symptoms of strep throat usually improve even without treatment in five days, but the patient is contagious for several weeks. Lack of treatment or incomplete treatment of strep throat can lead to various complications. Some of them may pose serious health risks. Therefore, streptococcal tonsillitis is important to recognize and treat early. Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson. Robbins Basic Pathology: With STUDENT CONSULT Online Access. Philadelphia: Saunders. ISBN 1-4160-2973-7.  8th edition. Page 537

Infectious complications

• The active infection may occur in the throat, skin, and in blood.
• Skin and soft tissues may become infected, resulting in redness, pain, and swelling. Skin and deep tissues may also become necrotic (rare).
• Herpes
• Scarlet fever is caused by toxins released by the bacteria.
• Rarely, some strains may cause a severe illness in which blood pressure is reduced and lung injury and kidney failure may occur (toxic shock syndrome).

Noninfective complications

• During the infection, antibodies (disease–fighting chemicals) are produced, sometimes causing a rare complication that can result after the organism is cleared, when these antibodies cause disease in body organs.
• Rheumatic fever is a heart disease in which the inflammation of heart muscle and scarring of heart valves can occur.
• Glomerulonephritis is a kidney disease which may lead to kidney failure.EMedicineHealth

See also

• PANDAS - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
• Tonsillitis
• Pharyngitis
• Psoriasis
• Herpes, as the symptoms of these two ailments are very similar, do not mistake one for the other.

References

world book encyclopedia

External links

• Group A Streptococcal Infections - National Institute of Allergy and Infectious Diseases.
• Post-infectious glomerulonephritis - mayoclinic.com.

v • d • e Pathology of respiratory system (J, 460–519)
Acute upper respiratory infections	Upper respiratory tract infection · Common cold · Rhinitis · Sinusitis · Pharyngitis (Strep throat) · Tonsillitis · Laryngitis · Tracheitis · Croup · Epiglottitis
Influenza and Pneumonia	Influenza · Pneumonia (Viral, Bacterial, Bronchopneumonia) · Severe acute respiratory syndrome
Other acute lower respiratory infections	Bronchitis (Acute, Chronic) · Bronchiolitis
Other diseases of upper respiratory tract	Vasomotor rhinitis · Hay fever · Atrophic rhinitis · Nasal polyp · Deviated septum · Adenoid hypertrophy · Peritonsillar abscess · Vocal fold nodule · Laryngospasm
Chronic lower respiratory diseases	Emphysema · COPD · Asthma · Status asthmaticus · Bronchiectasis
Lung diseases due to external agents	Pneumoconiosis (Coalworker\'s pneumoconiosis, Asbestosis, Silicosis, Bauxite fibrosis, Berylliosis, Siderosis) · Byssinosis · Hypersensitivity pneumonitis (Farmer\'s lung, Bird fancier\'s lung)
Other, principally affecting the interstitium	Acute respiratory distress syndrome · Pulmonary edema · Hamman-Rich syndrome · Interstitial lung disease
Suppurative and necrotic conditions of lower respiratory tract	Lung abscess · Pleural effusion · Empyema
Other	Pneumothorax · Hemothorax · Hemopneumothorax · Mendelson\'s syndrome · Respiratory failure · Atelectasis · Mediastinal emphysema · Mediastinitis
see also congenital (Q30–Q34, 748)

v • d • e Common cold
Viruses	Rhinovirus - Coronavirus - Human parainfluenza viruses - Human respiratory syncytial virus - Adenovirus - Enterovirus - Metapneumovirus
Symptoms	Pharyngitis - Rhinorrhea - Nasal congestion - Sneezing - Cough - Muscle aches - Fatigue - Malaise - Headache - Weakness - Loss of appetite
Complications	Acute bronchitis - Bronchiolitis - Croup - Pneumonia - Sinusitis - Otitis media - Strep throat
Antiviral drugs	Pleconaril (experimental)

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