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Clinical Summary

“Strep throat” is acute tonsillopharyngitis caused by Streptococcus pyogenes (group A β-hemolytic streptococci [GABHS]) in the majority, and occasionally by serogroups C and G. Strep throat is seen among schoolchildren (5–15 years) with a peak incidence during the first few years of school. The incubation period is 2 to 4 days. Presenting symptoms are abrupt onset with high fever, sore throat, pain on swallowing, malaise, headache, and abdominal pain. Pharynx is beefy red; palate and uvula may be edematous, reddened, and covered with petechiae. Tonsils are erythematous, enlarged with patches of a gray-white exudate giving a “strawberry” appearance (intensity of exudates either absent in mild cases to distinct membrane covering entire pharynx in severe cases). Tender anterior cervical lymphadenopathy at the angles of the mandibles is palpable.

Figure 3.1 ▪ Exudative Tonsillopharyngitis.

Exudative tonsillopharyngitis in an adolescent presenting with high fever, sore throat, and tender anterior cervical adenopathy and a throat culture positive for GABHS. Intensity of exudates can be absent in mild cases to formation of a membrane covering the entire pharynx in severe cases. (Photo contributor: Mark Silverberg, MD.)

Scarlet fever rash may appear 12 to 24 hours after the onset of fever. The patient’s forehead and cheeks are flushed with circumoral pallor and a rash of tiny papules that appears like a “sunburn with goose pimples,” has the texture of sandpaper, and blanches prominently with pressure. The rash begins in the axilla, groin, and neck and generalizes, sparing the palms, soles, and face within 24 hours. Other findings include strawberry tongue, exudative tonsillopharyngitis, and Pastia sign (an accentuation of the rash in skin folds with fine line of petechiae). Desquamation may occur after 7 to 10 days and usually continues for 2 to 3 weeks, but can last up to 2 months. When desquamation occurs, it begins as fine flakes on the face, then precedes over the trunk, hands, and feet. The extent and duration of desquamation are directly related to the intensity of the rash. Scarlet fever rash is caused by one or more of several erythrogenic exotoxins produced by GABHS strains and occurs in children who lack the immunity to the exotoxin. The portal of entry is oropharynx in the majority and rarely a surgical wound (surgical scarlet fever). Most cases occur in children between 2 and 8 years of age in winter and early spring.

Figure 3.2 ▪ Acute Suppurative Cervical Lymphadenitis.

Both throat culture and lymph node aspirate culture were positive for GABHS in this girl presenting with anterior cervical lymphadenitis. (Photo contributor: Binita R. Shah, MD.)

Both streptococcal pharyngitis and scarlet fever are self-limited diseases. Fever abates within 3 to 5 days (in absence of suppurative complications) with resolution of all signs and symptoms within 1 week. Tonsillar ...

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