It was sorta funny, wishing that my son had a strep throat. He had awakened, with a temp to 101 or so, and said it hurt to swallow. But hey, that was way back last spring, in the early, loopy days of the H1N1 outbreak, what with scary stories and weeklong quarantines at home for “flu like illnesses.” Yikes. And: how were we as a two-career, three-kid household supposed to deal with that? Kids with strep, I knew, often felt better (and, were back to school!) within 24-48 hours of starting antibiotics. Yeah, while a bummer, strep would be a lesser evil…So, my wife and I wondered then as folks do now: are all post-H1N1 sore throats due to flu viruses? And, is it easy to tell the difference? Kinda, sorta. Depends.

 

Even before H1N1, sore throats (aka pharyngitis) constitute about 10% of visits to the pediatrician’s office every year. Depending on the season, the group A streptococcal infections of the throat may constitute from about a quarter to half of all these cases, with viruses (including H1N1) constituting about a third, and the remainder being a gamish of other common bacteria or no identifiable bug at all.

 

Further, studies have shown us that parents, attending physicians, residents and medical students are equally incompetent at eyeballing a tender mouth and making a strep throat diagnosis. An infected throat can look normal. What’s more, a rip, roarin’ red hot pair of pus-covered tonsils can be due to strep as due to a viral infection, like mononucleosis. (And these are particularly icky, I’ll tell you. The term ‘tonsillar pseudomembranes’ says enough right there).

 

Fortunately, and as is so often the case, using key elements in the history can help tell the difference between a bacterial infection and a viral pharyngitis. For the child who has the the medical textbook version of strep, the classic story is exposure to a classmate or family member with strep, then a day or two of sore throat, fever >102, headache and stomach upset and, a sandpapery rash and a set of yellow tonsils to match. In real life, though, few kids have all of these things. Most have some of these symptoms AND a notable absence of virally symptoms. My suspicion for strep as an infection source plummets if a parent or child exhibits cough, sneezing and runny nose symptoms. Then, we are more thinking a viral cause is afoot. It’d be unlikely, and super unlucky, to have strep and a virus. Occam’s razor reminds us to keep our explanations simple. Age helps us, too. Strep rarely occurs in children under the age of 2, and is most common in school age kids. Viral infections, democratic as they are, occur at all ages.

 

Group A streptococcal infections can be benign, but they can get ugly. They do require treatment within 10 days of infection to prevent the unhappy complications of rheumatic fever. And, the antibiotics we use are inexpensive and work well. Happily, rapid testing is cheap and effective and good. Using throat swabs a 5-10 minute test can diagnose a strep infection with almost 99% specificity (meaning 1% or so false positive results). Translation: when your test is positive, we treat. A fairly high number of false negatives on these rapid tests (about a third) require throat cultures to cook for 48 hours confirm if there is a strep infection.

 

In cases where a child is strep negative by testing, and/or has a virally picture by history or exam (sore throat, sure, but gobs of boogers and a hacking cough), then it is all about what we docs call supportive care. Parents call this TLC plus or minus chicken soup. Anti-fever medication, plenty of fluids and rest are the cornerstone of nursing kids back to health, and beating strep or the viral crud. Tea with honey or lemon do help tender throats. And, a favorite herbal tea remedy I recommend widely is Throat Coat tea, like that famous tummy medicine, it coats, soothes, relieves (and, is safe, too). Of course, if you are concerned that your child seems more ill than expected, and doesn’t perk up with your care, contact your health care provider.

 

And as for that son of mine? Amidst a gaggle of classmates who were under H1N1 house arrest, his positive strep rapid strep was a welcome as his quick trip back to health. A day after amoxicillin, he was rarin’ to go and to get back to school for recess (more on that another time). We emerged from that illness humbled, but a little wiser: that even that even during H1N1 pandemics, group A strep never leaves the stage, it just blends a bit more in the crowd.

Photo by Hardin MD, CDC