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.
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.
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. If you have a good immune system, our bodies can easily overcome an occasional attack of strep.
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 10 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.
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