What are the clinical signs of strep throat?

Clinical Signs of Strep Throat

Strep throat presents with sudden-onset severe sore throat, fever (typically >101°F), tonsillopharyngeal erythema with or without exudates, tender anterior cervical lymphadenopathy, and notably the ABSENCE of cough—which when present strongly suggests viral rather than streptococcal etiology. 1, 2

Key Physical Examination Findings

Oropharyngeal findings:

• Tonsillopharyngeal erythema (redness and inflammation of tonsils and posterior pharynx) with or without patchy exudates 1, 2
• Beefy red, swollen uvula 1, 2
• Soft palate petechiae ("doughnut lesions")—highly suggestive when present 1, 2

Lymphatic findings:

• Tender, enlarged anterior cervical lymph nodes (cervical adenitis) 1, 2, 3

Systemic findings:

• Fever typically ranging from 101°F to 104°F (38.3°C to 40°C) 1, 2
• Headache 1, 2
• Nausea, vomiting, and abdominal pain (especially in children) 1, 2

Dermatologic findings:

• Scarlatiniform rash (when present, indicates scarlet fever variant) 1, 2

Critical Distinguishing Features from Viral Pharyngitis

Features that argue AGAINST strep throat and suggest viral etiology:

• Cough (highly suggestive of viral URI, uncommon in strep) 1, 4, 3
• Coryza (nasal discharge/rhinorrhea) 1, 2, 5
• Conjunctivitis 1, 2
• Hoarseness 1, 2
• Diarrhea 1, 5
• Discrete ulcerative stomatitis (mouth ulcers) 2

The American College of Physicians emphasizes that testing for strep should NOT be performed when these viral features are present. 1, 4

Clinical Presentation Pattern

Typical onset and course:

• Sudden onset of symptoms (not gradual) 1, 5, 6
• Pain on swallowing 1
• Symptoms generally of sudden onset distinguishing it from the more gradual onset of viral pharyngitis 1, 6

Age-Related Considerations

Peak incidence:

• Primarily affects children 5 to 15 years of age 1, 2, 3
• Uncommon in children younger than 3 years 1, 2

Atypical presentations in young children:

• Infants may present with excoriated nares or purulent nasal discharge rather than classic pharyngitis findings 1, 2
• Classic findings may be less apparent in children under 3 years 2

Epidemiological Context

Seasonal pattern:

• Winter and early spring in temperate climates 1, 2

Exposure history:

• Recent contact with documented case of strep pharyngitis increases likelihood 1, 2

Critical Diagnostic Limitation

No clinical finding is specific enough for diagnosis without laboratory confirmation. Even experienced clinicians cannot reliably distinguish streptococcal from viral pharyngitis based solely on physical examination, and microbiological confirmation with either rapid antigen detection test or throat culture is required. 1, 2 The American Heart Association emphasizes that none of these clinical manifestations individually is specific enough to diagnose GAS pharyngitis without laboratory testing. 1

Clinical Decision Algorithm

When to suspect strep throat (Modified Centor Criteria components):

• Fever by history 4, 3
• Tonsillar exudates 4, 3
• Tender anterior cervical adenopathy 4, 3
• Absence of cough (this is a criterion, not just presence of other symptoms) 4, 3
• Age 3-15 years 3

When NOT to test (viral features present):

• Any presence of cough, nasal congestion, conjunctivitis, hoarseness, or diarrhea argues strongly against strep and testing is not indicated 1, 4