THE ILLNESS - STREP THROAT: When the germ invades the throat of a susceptible person, the most common location of the infection is the tonsils, or in a child without tonsils, the back of the throat. Initial symptoms are high fever and sore throat, usually beginning 2-4 days after contact. It is most common in school age children. The degree of illness varies from mild to severe. A child may have low fever, 101-102, for a day or two, recover spontaneously and suffer no complications. Another child may have 104-105, be severely ill, and suffer serious complications. In addition to fever and sore throat, there is loss of appetite, difficulty swallowing, drowsiness, nausea and vomiting. Examination of the child reveals large, bright red tonsils, usually covered with a purulent (pus) exudate. Pin-head-size red spots (tiny hemorrhages) may be seen surrounding the tonsils and extending onto the palate. The lymph nodes in the neck are often swollen and tender.
THE ILLNESS - SCARLET FEVER: This condition represents an individual hypersensitivity to the toxins secreted by the GABHS and occurs in a relatively small percentage of children with strep throat. It begins on the same day as does the strep throat or a day or two later. It consists of a fine pin-point rash that feels like “goose flesh” on an area of bright, red skin. It begins on the body. The rash fades on pressure. It lasts 2-7 days, depending on the severity of the disease, and is followed by peeling of the skin (fine flakes to large sheets). The tongue may become slightly swollen, red , and mottled (“strawberry tongue”) and may also peel. The disease can be suspected by the appearance of the throat plus the remainder of the symptoms but the only sure way to confirm the diagnosis is by throat culture. Results are known in 12-24 hours. Rapid-Strep Tests have been developed which can be read in one to two hours. If the test is positive, one can reliably assume the sore throat is due to GABHS. Negative rapid-strep tests are only 60-75% accurate, so there is a possibility for error.
COMPLICATIONS: The primary GABHS infection is almost always self-limited and most children get well in 3-7 days. Without treatment, however, two to three weeks later, a small number of children develop serious complications, the most feared of which are acute rheumatic fever and acute glomerulonephritis. Some patients develop a streptococcal toxic-shock syndrome: high fever, low blood-pressure, collapse and coma. This complication has a high mortality rate.
TREATMENT OF CONTACTS: The majority of children with strep throat/scarlet fever respond well to penicillin. To prevent complications, it must be given for 10 days if oral penicillin is used. For children allergic to penicillin, erythromycin for 10 days is usually prescribed. In rare cases, other antibiotics may be necessary. It is usually not necessary to treat contacts unless an epidemic is in progress (this is usually defined as 2-3 cases within 5-7 days). Should this occur, the family physician and the school consulting physician should be notified. Household contacts would be more likely to require preventive antibiotic therapy than would school contacts.
STREP CARRIERS: A small percentage of children carry the GABHS in their throat but are not clinically sick. These children rarely spread the disease to others and most pediatricians feel they are not in any danger of developing complications. Therefore, it is not necessary for these children to receive antibiotics.
RETURN TO SCHOOL: Following initiation of treatment, it usually takes about 36-48 hours for the throat culture to revert to negative. Therefore, children sent home from school on Tuesday who go to the doctor that afternoon to receive an antibiotic, should not return until Thursday or Friday, even though they feel well by Wednesday.