Strep Throat Does Not Typically Include Eye Crusts as a Symptom
Eye crusts are not a typical symptom of strep throat and their presence suggests a viral rather than streptococcal etiology. 1
Distinguishing Strep Throat from Viral Infections
Group A streptococcal (GAS) pharyngitis presents with a specific constellation of symptoms that typically do not include eye involvement:
Typical Strep Throat Symptoms:
- Sudden onset of sore throat 1
- Fever (temperature greater than 100.4°F/38°C) 1
- Pain when swallowing 1
- Tonsillopharyngeal erythema with or without exudates 1
- Tender enlarged anterior cervical lymph nodes (lymphadenitis) 1
- Headache, nausea, vomiting, and abdominal pain (especially in children) 1
- Palatal petechiae 1
- Scarlatiniform rash in some cases 1
Symptoms Suggesting Viral Rather Than Strep Etiology:
- Conjunctivitis (eye redness, discharge, crusting) 1
- Coryza (nasal discharge) 1
- Cough 1
- Hoarseness 1
- Discrete ulcerative stomatitis (mouth sores) 1
- Viral exanthem (skin rash) 1
- Diarrhea 1
Clinical Significance
The presence of eye symptoms like conjunctivitis with crusting is an important clinical feature that helps differentiate viral from streptococcal pharyngitis:
- According to the Infectious Diseases Society of America (IDSA) guidelines, the presence of clinical features such as conjunctivitis strongly suggests a viral rather than a streptococcal etiology 1
- The IDSA specifically lists conjunctivitis as a feature of viral infection in their comparison table of streptococcal versus viral pharyngitis features 1
- Diagnostic testing for strep throat is not recommended if clinical features strongly suggest a viral etiology (such as conjunctivitis) 1
Common Viral Causes of Pharyngitis with Eye Symptoms
Several viral pathogens can cause both pharyngitis and conjunctivitis with eye crusting:
- Adenovirus is a common cause of pharyngoconjunctival fever, presenting with pharyngitis, conjunctivitis, and fever 1
- Other respiratory viruses that can cause both sore throat and eye symptoms include parainfluenza virus, rhinovirus, and respiratory syncytial virus 1
- Enterovirus infections may present with both pharyngitis and conjunctivitis 1
Clinical Approach
When evaluating a patient with sore throat and eye crusts:
- The presence of eye crusts (conjunctivitis) should direct clinical suspicion toward viral rather than streptococcal etiology 1
- Testing for strep throat is generally not needed when overt viral features like conjunctivitis are present 1
- If conjunctivitis is present with pharyngitis, consider viral causes such as adenovirus 1
- Remember that viral conjunctivitis often presents with watery discharge that may crust, particularly after sleep 1
Pitfalls to Avoid
- Don't assume all sore throats require strep testing - the presence of conjunctivitis with eye crusting strongly suggests a viral etiology 1
- Avoid unnecessary antibiotic use for viral pharyngitis with conjunctivitis 1
- Be aware that some patients may have concurrent infections (both viral and streptococcal), though this is less common 2
- Remember that clinical scoring systems like the modified Centor score consider the absence of cough and conjunctivitis as factors that increase the likelihood of strep throat 3