WHAT'S A STREP? by Mark B. Levin, M.D. and Timothy Patrick-Miller, M.D. The Pediatric Group, P.A., Princeton

This is the twentysixth article in a series written for Princeton Online. Click here for an archive of other articles.

Although we hear about strep all the time, parents are often confused about the difference between strep throat, strep pneumonia, tonsillitis, pharyngitis and myriad other terms that may or may not relate to the most commonly referenced infection - strep throat.

All forms of strep are bacteria. Bacteria, in contrast to viruses, respond to antibiotic treatment. When the throat (pharynx) is infected, regardless of the germ that is causing the infection, the clinical condition is called pharyngitis. The tonsils, lymph glands visible on either side of the throat's back wall, are part of the body's immune system. When the tonsils are infected, the term is tonsillitis. In the days before throat cultures were available for regular use, doctors had no way of differentiating viral from bacterial throat infections. Every case of pharyngitis or tonsillitis was treated with an antibiotic. We know now that most pharyngitis and tonsillitis, even with pus on the tonsils, are viral. Viral infections and many bacterial infections resolve themselves harmlessly. We are also more aware of the disadvantages (allergic reactions, bacterial resistance, exposure to contaminants) of prescribing antibiotics for every infection. So, antibiotic use is much more selective.

Technically, strep is a shortening of "streptococcus", which means round bacteria that look like a beaded chain when examined under the microscope. The two most common categories of streptococcal germs are the strep pyogenes and strep pneumonia. Strep pneumonia is the bacterium most commonly responsible for bacterial meningitis, blood infections, bone infections, ear infections and, of course, pneumonia. It is to prevent infections with this organism that the popular "pneumonia vaccine" for senior citizens and the pneumococcal conjugate vaccine for children have been developed. Strep pneumonia, also termed pneumococcus, rapidly develops resistance to antibiotics, making repeat infections common and more difficult to eradicate.

Strep pyogenes is also called Group A beta-hemolytic streptococcus. This is the germ responsible for the common strep throat, aka strep pharyngitis or strep tonsillitis, and the far less common but more publicized "flesh eating strep". Close relatives of this germ, groups B, C and G beta-hemolytic streptococcus, can cause similar clinical infections, but are not as worrisome because they are not generally responsible for acute rheumatic fever, rheumatic heart disease and acute glomerulonephritis (kidney inflammation). It is the Group A strep for which doctors search in a throat culture and treatment with antibiotics is prescribed. Cultures that are incubated overnight are the most accurate. The newer rapid result cultures are more convenient in this fast-food disposable world, but they are not as accurate, especially when negative. Your doctor can explain which technique is the best for your particular situation.

Although the only sure way to identify strep throat is through the use of a throat culture, certain symptom combinations can be a tip-off of strep throat infection. In pre-adolescent children, the most common symptoms of strep throat are headache, abdominal pain and fever. Surprisingly, complaints of a sore throat, though customary in adolescents and adults, are habitually absent in younger children. The abdominal pain suffered by young children with strep throat can be so severe as to be mistaken for appendicitis. Children can complain of swollen glands in the front of the neck under the jaw. Occasionally, bloody urine can signal strep throat. Some strains of Group A strep produce a protein that causes the skin to become red and coarse. When this rash is present, especially when the child also has fever, it is called "scarlet fever". We know now that scarlet fever (also called scarlatina) is nothing more than (and no more dangerous than) strep throat with a strain that also causes the rash.

On examination, the throat may not even be particularly red! In adolescents and adults, sore throat is a common symptom and abdominal pain is rare. Differentiating strep infection from a virus in children under two years of age can be difficult since both conditions can present runny nose, fever and crankiness. Knowing if a child has been exposed to strep may help guide the diagnostic process. The time from exposure until developing symptoms (incubation period) is two to five days. Since strep is typically a winter and spring infection, doctors do not keep it as high on their diagnostic list in the summer and fall.

Strep throat is one of the conditions that always require antibiotics, more for prevention of rheumatic heart disease than relief of symptoms. Once treatment is begun, symptoms abate rapidly. Although the total course of treatment must always be completed (different but equally effective antibiotic regimens may be prescribed according a patient's individual needs), one day of treatment in the absence of symptoms renders the patient non-contagious.

Early recognition and treatment of strep throat can minimize school absences (one to five episodes each winter for school age children is not unusual) and prevent serious long term complications. Enjoy your summer and keep strep in mind when winter returns.

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Timothy Patrick-Miller

Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.