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with Rod Moser, PA, PhD

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Wednesday, September 15, 2010

Strep Is Always Going Around

The Top 12 Reasons Kids are Excluded from School Part Two

In my last post, I discussed some fever facts and why schools and day cares exclude children with fever. Today, I’ll look at reason number two: strep.

sore throat exam

Stockbyte

“Strep is going around.” I hear this statement nearly every day. News Flash: Strep is always going around, but it is more prevalent during the fall/winter school months. The vast majority of sore throats are viral, but some turn out to be strep. Just the way people called bad headaches “migraines” when they have never been medically-diagnosed with this specific type of vascular headache, people tend to refer to a bad sore throat as strep. Viral sore throats, especially those caused by the Epstein-Barr virus, the virus that causes mononucleosis, can be just as bad or worse.

Strep cannot be accurately diagnosed by the severity of the sore throat — it requires both a hands-on medical examination and a lab test for confirmation. Medical providers who feel they can just look in the throat and accurately diagnose strep, tend to be wrong half of the time; not much better than a coin toss.

“Do I have Strep or not?”

“Well, let’s see. Heads for strep, tails for a virus.”

When someone tells me that their husband was diagnosed with strep, I always inquire how he was diagnosed. If it was just one of these look-and-see examinations, I tend not to take it as seriously as someone who was properly diagnosed using a culture or rapid strep test.

There are some suspicious signs of strep that one can notice by simply looking at the throat. Many people get all excited when they see “white stuff” on the tonsils. This is not a definite sign of strep, and can even be food particles. Strep tends to cause petechiae — tiny, irregularly-shaped red dots appearing on the back of the palate, and on or near the uvula. The back of the throat and palate area is usually an angry-looking, fire-engine red. The kids look and act sick. Their breath smells like they have never used a toothbrush in their life. For those clinicians who have spent their careers insulted by this strep smell, we usually have a pretty good idea that this child probably has strep. I still test them. If the rapid strep test is surprisingly negative (it is not 100%), I tend to get a throat culture. A culture takes two days, but the accuracy approaches 100 percent.

I diagnosed a child with strep two weeks ago. The presence of strep was confirmed by a rapid strep test (takes about five minutes), the presence of some characteristic findings in the throat, and he was properly treated. Now, two weeks later, the mother calls me. She wants me to just treat the other five kids; only one who claims to have a sore throat. She is convinced that all of them have it, or will get it soon. I refused, insisting that she bring them all in for examinations. She only brought in the one complaining about a sore throat. The exam was normal; and her strep test was negative. This is why strep should not be treated over the phone.

Many years ago, I was plagued by a large family that had recurrent strep throats. Mom, Dad and the six kids would all get strep every few weeks, and missed lots of school. I even tested them at the end of treatment to make sure they were cured, since up to 10 percent or more of people are strep carriers (they always have detectable strep in their throats). So, it was eight strep tests, eight positive results, and eight prescriptions for penicillin. No matter what I did, they got it back again. Who was the mysterious culprit?

On the way to work, I listened to a news report about dogs being able to transmit strep. I thought about my own canine face-lickers, so I gave the mother a call. They had a dog; Duff, a large, friendly yellow Lab. I asked her to bring the dog the next time the kids got strep.

Duff was sitting by the back door of my office, his huge tongue wagging like his tail. I swabbed his throat and Duff had strep, too. The HMO never knew anything about this. It was just a “Lab” test!  Nine prescriptions later, including the one clandestine one for Duff, the family was cured. I never saw them again for strep over the next several years. This one extra “Lab” test, saved the HMO a lot of money in the long run.

Streptococcal infections have a bad, historical reputation, since it has the potential to cause heart-damaging rheumatic fever, kidney disease, life-threatening pneumonia, and other serious complications. The reason why we treat strep when we diagnosis is to prevent these complications that are relatively rare now. Many of us have had strep in our lives, and were never tested nor treated. We survived and we didn’t get any of these complications. If you have a good immune system, our bodies can easily overcome an occasional attack of strep.

In the days before the rapid strep tests, about twenty years ago, we actually saw less recurrent strep. Now that strep can be rapidly diagnosed in about five minutes, perhaps on the first day of the illness, we tend to treat it. Rapid antibiotic treatments circumvent our own immune responses, so the body becomes more prone to getting it again. In the days were we had to anxiously wait two or three days to find out if a person had strep or not, the body would use this time to build up antibodies; antibodies that would still be there to protect us against future infections. I don’t have a particular recommendation about this, but I find it interesting. It does emphasize the point that we should not always jump the gun and go directly to antibiotics.

Kids who are excluded from school with strep should have at least 24 hours of treatment, and show improvement before returning to school. Treatment with antibiotics, usually a penicillin-based one if you are not allergic to them, will last about ten days. There is really no need to keep children home that long. I always recommend that they change their toothbrush after a day of treatment, since strep can colonize on wet toothbrushes. If you have several kids who keep their toothbrushes in the same drawer, touching, it is the same as sharing toothbrushes. For the teenagers, I warn them about taking a clandestine swig out of the milk or orange juice container in the refrigerator when no one is watching.

If a sore throat persists more than a week or so, accompanied by fatigue, a mono test should be considered.

A final word: Have a lab test, or in some cases test the Lab!

Have you suspected strep following a sore throat? Were you right or wrong? Post your comments on the Ear, Nose and Throat Community.

Posted by: Rod Moser, PA, PhD at 9:44 am

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