The three siblings would have made a nice pediatric teaching case, but no medical students were in the office that busy winter afternoon.
The little girl came in first with vaginal itching, redness and discharge, while her 9-year-old brother followed, complaining of a sore throat. Though number three wasn't on my schedule, mom asked me to take a look at their brother, who was very crabby and had a mysterious, fine pink rash on his torso.
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It turned out that these children were all exhibiting interesting manifestations of the same common Group A streptococcus bacteria: strep vaginitis, strep throat, and a scarlet fever rash.
According to Dr. Michael R. Wessels in the New England Journal of Medicine, GAS causes 20-30 percent of childhood sore throats and most often affects children between the ages of 5 and 15. In our part of the world, as in most temperate climates, strep tends to peak in winter and in early spring.
In their 2012 Update by the Infectious Diseases Society of America, Dr. Stanford Shulman and colleagues recommend that a throat swab be performed when strep is suspected, since it's often difficult to tell if a child is suffering from a GAS bacterial pharyngitis or the even more widespread viral version.
The IDSA notes that the presence of pink eye, common cold symptoms, cough, diarrhea, hoarseness, mouth ulcers and viral rashes are more typical of a viral sore throat.
The sudden onset of a sore throat, with possible fever, headache, nausea, vomiting, and abdominal pain, and a fine "sandpaper" rash are among several clinical features suggestive of a diagnosis of Group A streptococcal pharyngitis.
If testing is negative for GAS, then providers can avoid the inappropriate use of antibiotics for a viral infection. If the throat swab comes back positive for strep, specialists advise antibiotics to help prevent cases of acute rheumatic fever (now uncommon in the U.S. and other developed countries), as well as other complications of invasive GAS.
Prompt strep diagnosis and treatment can also help the infected child feel better faster and make him less likely to pass the bacteria on to close family and friends. These are significant factors both medically and financially since -- if lost parental work days are counted -- pediatric strep throat costs the U.S. economy approximately half a billion dollars annually.
Though it's certainly reasonable to perform a strep test on a parent or sibling of a strep throat patient if that particular family member is also experiencing strep symptoms, Dr. Shulman's team does not recommend the routine testing or treatment of asymptomatic household contacts.
IDSA guidelines state that a 10-day course of penicillin V is the treatment of choice for strep throat since it is an effective, safe, inexpensive, and "narrow spectrum" antibiotic. The group finds that amoxicillin is equally effective against GAS, and reports that amoxicillin is often used instead of penicillin in cases of pediatric strep throat due to its more pleasant taste.
For penicillin-allergic patients, treatment possibilities are first generation cephalosporins such as cefadroxil (Duricef) or cephalexin (Keflex), but only if the child's penicillin reaction is not of the more severe "anaphylactic" type, since up to 10 percent of penicillin-allergic individuals can also be allergic to cephalosporins.
Other options for antibiotic treatment of strep pharyngitis in penicillin-allergic children include clindamycin, clarithromycin (Biaxin), or azithromycin (Zithromax).
Experts in the American Academy of Pediatrics Redbook explain that strep throat develops within two to five days of contact with the respiratory tract secretions of an individual with Group A streptococcal pharyngitis. Infected children are advised to avoid close contact with other children, and so should not attend day care or school until at least 24 hours after their first dose of antibiotics.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.