Group A Streptococcus (GAS): Signs and Symptoms

by John Fisher, MD

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    00:01 So let’s get back to the symptoms and other clinical features of group A streptococcal pharyngitis.

    00:10 Number one, and it’s usually a pretty bad sore throat, is painful swallowing.

    00:18 And in addition to that, the patients will very often have fever, not extremely high-grade, but at least 38.5 or more, and they may even have some GI symptoms, which can deter the physician from making a specific diagnosis.

    00:38 They will have nausea, vomiting, and abdominal pain, which is sometimes confusing to the physician evaluating the patient.

    00:46 Most patients have a bright red posterior pharynx with tonsillar enlargement and they have often have exudative tonsillitis, meaning a gray-white exudate covering one or both tonsils.

    01:04 And a clue that’s often missed is edema of the uvula, which you may be able to detect in this particular view.

    01:17 Another finding is that of petechiae on the soft palate.

    01:25 In addition, many patients have painful anterior cervical lymphadenopathy.

    01:34 Of utmost importance is the absence of a cough.

    01:40 So if you have a patient that’s got sore throat, cough, hoarseness, nasal congestion, that’s probably not group A strep.

    01:52 That’s probably a viral pharyngitis, bronchitis, laryngitis, it’s viral.

    02:00 So the absence of a cough is an important point in the evaluation of someone with a sore throat.

    02:08 Some patients, if they have a particular strain of group A strep that produces this toxin, they may have a scarlatiniform rash, the so-called rash of scarlet fever.

    02:22 This begins on the trunk and generally tends to spare the extremities.

    02:29 And if you look at the creases in the elbows, they may be slightly darkened.

    02:35 These are referred to as Pastia's lines.

    02:39 And this rash has a sandpaper-like quality because the sweat glands are slightly edematous and you can feel the skin having sort of a rough texture to it.

    02:56 Some other conditions that one needs to consider in the evaluation are certainly herpangina, which is caused by Coxsackie A virus most commonly.

    03:08 And you may be able to note the vesicles and ulcers on the soft palate.

    03:17 And one thing about herpangina is most of the lesions tend to be posteriorly located in the pharynx.

    03:28 We certainly wouldn’t want to miss diphtheria, these patients have an adherent gray membrane, and then infectious mononucleosis.

    03:39 They also may have palatal petechiae like group A strep.

    03:46 The difference would be this is more of a subacute illness than an acute illness like group A strep.

    03:55 And then we can’t forget oral candidiasis and you should note the white plaques that you find and they can be in the buccal mucosa, on the posterior pharynx, they can be on the tongue.

    04:08 And the pearl is, if you have a patient coming in with pharyngitis with oral candidiasis, they need an HIV test.

    04:21 Other streptococci can also cause pharyngitis, group C and G.

    04:28 But I want to spend a moment on Fusobacterium necrophorum, which is an unusual cause of pharyngitis and seems to occur most commonly in young adults, and the pharyngitis may be indistinguishable, at least the way it looks, from group A strep pharyngitis.

    04:49 But what I wanted to focus on are the complications.

    04:52 This organism is an anaerobe and it can cause blood to clot in veins, so it can cause a peritonsillar abscess.

    05:03 And what we fear most about this organism is the syndrome called Lemierre’s syndrome, which is characterized by suppurative jugular venous thrombophlebitis.

    05:17 So the jugular vein is closed off by a clot and, furthermore, it’s an infected clot, and so as an infected clot, it can disseminate organisms all over the place.

    05:31 For example, these patients may have abscesses in their lungs, they may have positive blood cultures, they may be deathly ill.

    05:41 So we can’t overlook the possibility of Fusobacterium necrophorum and Lemierre’s syndrome.

    05:52 This is an organism that reportedly produces a syndrome very much like group A strep pharyngitis called Arcanobacterium haemolyticum.

    06:04 It must be very rare.

    06:07 I think you can see that I’ve probably seen many patients in my years, but I have yet to recognize this.

    06:13 But you need to know that it can produce a scarlatiniform rash, so it can mimic, and I’m waiting.

    06:23 More about Corynebacterium diphtheriae.

    06:26 On Gram stain, these organisms are Gram-positive bacilli and they tend to clump together, some people say, like Chinese lettering, and we don’t find this in developed countries because people are immunized.

    06:45 But in a developing country, a patient may come in with this diphtheriae and they may present with a sore throat, low-grade fever, and they will have this adherent, gray membrane that’s difficult to remove.

    07:00 And by the way, this membrane can be located not only on the tonsils, but this can actually occlude the airway, it can get into the larynx, and is a cause of asphyxiation in minority of patients.

    07:16 So we need to be able to make this diagnosis and protect the airway if necessary.

    07:26 The other thing these patients have is very impressive cervical lymphadenopathy.

    07:32 The lymphadenopathy is so impressive that it may give the patient, as in this young girl, a bull neck type appearance.

    07:45 And of course we can’t forget to at least consider Neisseria gonorrhoeae by taking a careful sexual history.

    07:54 Generally, it does not cause a very severe sore throat.

    07:59 In fact, you can actually be colonized by Neisseria gonorrhoeae without any symptoms.

    08:05 So paramount is taking a good sexual history, and there are the organisms on Gram stain, Gram-negative diplococci.

    08:17 Mycoplasma pneumoniae and Chlamydophila pneumoniae usually produce kind of a viral-like syndrome and they will often have headache, cough, fatigues, or remember, if they’ve got cough, it’s not very likely group A strep infection.

    08:38 And they will have sore throat in from 30% to 70%.

    08:42 And particularly with Chlamydophila, the incubation period is actually quite long, maybe two or three weeks since they were exposed to someone who had something similar.

    08:56 Now, for infectious mono, we need to spend some time on this disease because it’s fairly common.

    09:04 But I want to emphasize that this is a subacute illness.

    09:09 These patients have been complaining of the sore throat and fatigue for maybe two or three weeks Finally, they come to the doctor.

    09:19 One interesting point is that when they first went to the doctor with their sore throat, they may have been given amoxicillin and developed a rash and so they were told they were probably allergic to amoxicillin.

    09:37 On exam, you find mild to moderate tonsillar enlargement with exudates.

    09:42 So the exudates can look an awful lot like a group A strep and they also may have those palatal petechiae.

    09:51 They will have very impressive lymphadenopathy, and it’s not only anterior cervical, but it’s posterior cervical lymphadenopathy, and in my experience, axillary lymphadenopathy is common and splenomegaly.

    10:07 And as a matter of fact, if you suspect infectious mono in a patient, you should carefully examine the abdomen for a palpable spleen.

    10:18 And if this is a young athlete, then you need to advise them that they need to stay away from contact sports if they have splenomegaly, because if they have splenomegaly and they get trauma to their left side, then they can actually rupture their spleen and bleed out.

    10:41 So a physician needs to really carefully evaluate somebody with mono for splenomegaly.

    10:49 And regardless of what you do, they will gradually get better over about a month.

    10:56 But this is kind of a nagging illness for teenagers.

    11:00 It is spread by intimate kissing, and as you can imagine, that’s pretty common in teenagers so we need to have our antenna up for this cause of sore throat.

    11:16 And then once again, remember that -- and this is curious -- that if they get antibiotics, particularly amoxicillin, a large percentage of them will break out with a rash and then the amoxicillin will forever be listed as an allergy.

    11:37 But it’s not related to an allergy to amoxicillin, it’s just something related to infectious mononucleosis which we don’t clearly understand.

    11:48 It’s an idiosyncrasy of that illness.

    About the Lecture

    The lecture Group A Streptococcus (GAS): Signs and Symptoms by John Fisher, MD is from the course Upper Respiratory Infections. It contains the following chapters:

    • Signs/Symptoms – Group A Streptococcus (GAS)
    • Signs/Symptoms – Non-Group A Streptococcus
    • Atypical Bacteria

    Included Quiz Questions

    1. Coxsackie A16
    2. Herpes simplex virus I
    3. Enterovirus 61
    4. Echovirus
    5. Adenovirus
    1. Advising against contact sports for the time being
    2. Documenting hypersensitivity to beta-lactam antibiotics for future prescriptions
    3. Prescribing a macrolide
    4. Desensitizing the patient to amoxicillin
    5. Referring the patient for hospitalization
    1. No further tests required at this time
    2. Complete blood count
    3. Serum electrolytes
    4. Polymerase chain reaction of respiratory tract secretions
    5. Culture of vesicular fluid
    1. Jugular venous thrombophlebitis
    2. Pulmonary embolism
    3. Acute renal failure
    4. Seizures
    5. Suppurrative lymphadenitis
    1. Corynebacterium diptheriae
    2. Neisseria gonorrhoeae
    3. Coxsackie A16
    4. Fusobacterium necrophorum
    5. Mycoplasma pneumoniae

    Author of lecture Group A Streptococcus (GAS): Signs and Symptoms

     John Fisher, MD

    John Fisher, MD

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    Excellent DDx for pharyngitis!
    By Varvara K. on 14. August 2019 for Group A Streptococcus (GAS): Signs and Symptoms

    What an excellent lecture! I have not seen a comparison of pharyngitis causes shown next to each other so clearly until now. Having the images of throat presentations displayed on the same slide as the narrative goes on was very helpful. Thank you!