So let’s get back to the symptoms and other clinical features
of group A streptococcal pharyngitis.
Number one, and it’s usually a pretty bad sore throat,
is painful swallowing.
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.
They will have nausea, vomiting, and abdominal pain,
which is sometimes confusing to the physician evaluating the patient.
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.
And a clue that’s often missed is edema of the uvula,
which you may be able to detect in this particular view.
Another finding is that of petechiae on the soft palate.
In addition, many patients have painful anterior cervical lymphadenopathy.
Of utmost importance is the absence of a cough.
So if you have a patient that’s got sore throat, cough,
hoarseness, nasal congestion,
that’s probably not group A strep.
That’s probably a viral pharyngitis, bronchitis, laryngitis,
it’s viral.
So the absence of a cough is an important point
in the evaluation of someone with a sore throat.
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.
This begins on the trunk and generally tends to spare the extremities.
And if you look at the creases in the elbows, they may be slightly darkened.
These are referred to as Pastia's lines.
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.
Some other conditions that one needs to consider in the evaluation
are certainly herpangina, which is caused by Coxsackie A virus most commonly.
And you may be able to note the vesicles
and ulcers on the soft palate.
And one thing about herpangina is most of the lesions tend to be
posteriorly located in the pharynx.
We certainly wouldn’t want to miss diphtheria,
these patients have an adherent gray membrane,
and then infectious mononucleosis.
They also may have palatal petechiae like group A strep.
The difference would be this is more of a subacute illness
than an acute illness like group A strep.
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.
And the pearl is, if you have a patient coming in with pharyngitis
with oral candidiasis, they need an HIV test.
Other streptococci can also cause pharyngitis, group C and G.
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.
But what I wanted to focus on are the complications.
This organism is an anaerobe
and it can cause blood to clot in veins,
so it can cause a peritonsillar abscess.
And what we fear most about this organism is the syndrome called Lemierre’s syndrome,
which is characterized by suppurative jugular venous thrombophlebitis.
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.
For example, these patients may have abscesses in their lungs,
they may have positive blood cultures, they may be deathly ill.
So we can’t overlook the possibility
of Fusobacterium necrophorum and Lemierre’s syndrome.
This is an organism that reportedly
produces a syndrome very much like group A strep
pharyngitis called Arcanobacterium haemolyticum.
It must be very rare.
I think you can see that I’ve probably seen many patients in my years,
but I have yet to recognize this.
But you need to know that it can produce a scarlatiniform rash,
so it can mimic, and I’m waiting.
More about Corynebacterium diphtheriae.
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.
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.
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.
So we need to be able to make this diagnosis
and protect the airway if necessary.
The other thing these patients have is very impressive cervical lymphadenopathy.
The lymphadenopathy is so impressive that it may give the patient,
as in this young girl, a bull neck type appearance.
And of course we can’t forget to at least consider Neisseria gonorrhoeae
by taking a careful sexual history.
Generally, it does not cause a very severe sore throat.
In fact, you can actually be colonized by Neisseria gonorrhoeae without any symptoms.
So paramount is taking a good sexual history,
and there are the organisms on Gram stain, Gram-negative diplococci.
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.
And they will have sore throat in from 30% to 70%.
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.
Now, for infectious mono, we need to spend some time
on this disease because it’s fairly common.
But I want to emphasize that this is a subacute illness.
These patients have been complaining of the sore throat
and fatigue for maybe two or three weeks
Finally, they come to the doctor.
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.
On exam, you find mild to moderate tonsillar enlargement with exudates.
So the exudates can look an awful lot like
a group A strep and they also may have those palatal petechiae.
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.
And as a matter of fact, if you suspect
infectious mono in a patient,
you should carefully examine the abdomen for a palpable spleen.
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.
So a physician needs to really carefully evaluate somebody with mono
for splenomegaly.
And regardless of what you do, they will gradually get better over about a month.
But this is kind of a nagging illness for teenagers.
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.
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.
But it’s not related to an allergy to amoxicillin,
it’s just something related to infectious mononucleosis
which we don’t clearly understand.
It’s an idiosyncrasy of that illness.