Symptoms of Streptococcal Pharyngitis
Group A streptococcal pharyngitis typically presents with sudden onset of severe sore throat, fever, tonsillar exudates, and tender anterior cervical lymph nodes—notably WITHOUT cough, which strongly suggests viral infection instead. 1
Classic Streptococcal Symptoms
The hallmark features that suggest bacterial strep throat include:
- Sudden onset of sore throat with pain on swallowing 1
- Fever (temperature >100.4°F or 38°C) 1, 2
- Tonsillopharyngeal exudates (white patches on tonsils) 1
- Tender, enlarged anterior cervical lymph nodes (lymphadenitis) 1
- Absence of cough (this is a key distinguishing feature) 1, 3
Additional Supportive Features
Other symptoms that may accompany strep throat include:
- Headache, nausea, vomiting, and abdominal pain (especially common in children) 1, 4
- Swollen, beefy red uvula 1
- Palatal petechiae (small red spots on the roof of the mouth) 1
- Scarlatiniform rash (sandpaper-like rash associated with scarlet fever) 1
- Swollen tonsils with tonsillopharyngeal erythema (redness) 1
Key Distinguishing Features: What Suggests VIRAL (Not Strep)
The presence of any of these symptoms strongly suggests viral pharyngitis and argues against strep throat:
- Cough (highly suggestive of viral origin) 1, 5
- Nasal congestion or runny nose (coryza) 1
- Conjunctivitis (pink eye) 1
- Hoarseness 1
- Diarrhea 1
- Discrete oral ulcers or vesicles 1
Epidemiological Context
Strep throat is most common in:
- Children aged 5-15 years (though it occurs in adults at lower rates) 1
- Winter and early spring months 1
- Patients with known exposure to documented strep cases 1
Clinical Decision-Making with Centor Criteria
The modified Centor criteria help stratify risk and guide testing decisions. One point is assigned for each of the following four features: 1, 3
- Fever by history
- Tonsillar exudates
- Tender anterior cervical adenopathy
- Absence of cough
Patients with fewer than 3 Centor criteria have low probability of strep and do not need testing. 1, 3 Those with 3-4 criteria should undergo rapid antigen detection testing or throat culture to confirm the diagnosis before treatment. 1, 3
Important Clinical Caveat
Even with all four Centor criteria present, only about 50% of patients actually have strep pharyngitis, which is why confirmatory testing with rapid antigen detection test or throat culture is essential rather than treating empirically based on symptoms alone. 6 The Centor criteria have low positive predictive value, so they are best used to identify patients who do NOT need testing (scores 0-2) rather than to diagnose strep definitively. 1, 3