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Key Features

Essentials of Diagnosis

Streptococcal pharyngitis

  • Clinical diagnosis based entirely on symptoms; signs and physical examination unreliable

  • Throat culture or rapid antigen detection test positive for group A streptococci


  • Rapidly spreading, highly infectious skin rash

  • Erythematous denuded areas and honey-colored crusts

  • Group A streptococci are grown in culture from most (not all) cases

General Considerations

  • Group A streptococci (GAS) produce a wide variety of clinical illnesses, including acute pharyngitis, impetigo, cellulitis, and scarlet fever

  • Can also cause pneumonia, septic arthritis, osteomyelitis, meningitis, and other less common infections

  • May also produce postinfectious sequelae (rheumatic fever and acute glomerulonephritis).

  • Almost all GAS are β-hemolytic

Clinical Findings

Symptoms and Signs

  • Respiratory infections in children younger than 3 years

    • Onset is insidious

    • Symptoms are mild (low-grade fever, serous nasal discharge, and pallor)

    • Otitis media is common

    • Exudative pharyngitis and cervical adenitis are uncommon in this age group

  • Respiratory infections in children older than 3 years

    • Presents with the sudden onset of fever, sore throat, malaise, and often vomiting

    • Tonsillar exudate and tender anterior cervical adenopathy are usually noted

    • Petechiae are frequently seen on the soft palate

  • Scarlet fever

    • Skin is diffusely erythematous and appears sunburned and roughened (sandpaper rash); most intense in the axillae, groin, and on the abdomen and trunk

    • It blanches except in the skin folds, which do not blanch and are pigmented (Pastia sign)

    • Rash usually appears 24 hours after the onset of fever and rapidly spreads over the next 1–2 days

    • Desquamation begins on the face at the end of the first week and becomes generalized by the third week

    • Early in the infection, there is circumoral pallor and the surface of the tongue is coated white, with the papillae enlarged and bright red (white strawberry tongue)

    • Subsequently desquamation occurs, and the tongue appears beefy red (strawberry tongue)

    • Petechiae may be seen on any mucosal surfaces

  • Impetigo

    • Begins as a papule that vesiculates and then breaks, leaving a denuded area covered by a honey-colored crust

    • Lesions spread readily and diffusely

    • Local lymph nodes may become swollen and inflamed

    • Although the child often lacks systemic symptoms, a high fever and toxicity may be present

  • Cellulitis

    • Local acute lymphadenitis occurs

    • Child is usually acutely ill, with fever and malaise

    • Streptococcal perianal cellulitis

      • Causes pain with defecation, often leadings to constipation

      • Perianal erythema, tenderness, and painful rectal examination are only abnormal physical findings

      • Scant rectal bleeding with defecation may occur

    • Streptococcal vaginitis is a variant of perianal cellulitis

      • Symptoms are dysuria and pain

      • Marked erythema and tenderness of the introitus and blood-tinged discharge are seen

  • Necrotizing fasciitis

    • About 20–40% of cases are due to GAS

    • Characterized by extensive necrosis of superficial fasciae, undermining of surrounding tissue, and usually systemic toxicity

  • Streptococcal sepsis

    • Rash and scarlet fever may be ...

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