Can a Child Have Strep Tonsillitis with Cough?
No, the presence of cough strongly suggests a viral etiology rather than streptococcal tonsillitis, and diagnostic testing for Group A Streptococcus should not be performed when cough is present. 1
Clinical Reasoning
The Infectious Diseases Society of America (IDSA) explicitly lists cough as a feature of viral infection, not streptococcal pharyngitis/tonsillitis. 1 When clinical features strongly suggest a viral etiology—specifically cough, rhinorrhea, hoarseness, or oral ulcers—diagnostic testing for Group A Streptococcus is not recommended. 1
Distinguishing Features
Group A Streptococcal Tonsillitis typically presents with: 1
- Sudden onset sore throat
- Fever
- Tonsillopharyngeal inflammation with or without exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
- Age 5-15 years (peak incidence) 2
- Nausea, vomiting, or abdominal pain (especially in boys) 3
Viral pharyngitis/tonsillitis typically presents with: 1
- Cough
- Coryza (runny nose)
- Conjunctivitis
- Hoarseness
- Diarrhea
- Discrete ulcerative stomatitis
Diagnostic Approach
When cough is present: Do not test for streptococcal infection, as the likelihood of bacterial etiology is extremely low and testing will lead to unnecessary antibiotic use. 1 The child should receive supportive care with analgesia and hydration. 4
When cough is absent and streptococcal features are present: Proceed with rapid antigen detection testing and/or throat culture. 1 A positive rapid test is diagnostic; negative tests in children require backup culture due to higher risk of rheumatic fever complications. 1
Important Caveats
Chronic Cough Considerations
If a child develops chronic cough (>4 weeks duration) following an acute illness that may have included tonsillitis, alternative etiologies must be considered: 1
Pertussis or Mycoplasma pneumoniae infection: These can cause prolonged cough (median 51 days for pertussis, mean 23 days for Mycoplasma) and may occur even in vaccinated children. 1 Consider testing when pertussis is clinically suspected with post-tussive vomiting, paroxysmal cough, or inspiratory whoop. 1
Protracted bacterial bronchitis (PBB): If chronic wet/productive cough develops without specific cough pointers (feeding-related cough, digital clubbing), treat with 2 weeks of antibiotics targeting Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis based on local sensitivities. 1
Age-Specific Considerations
Children under 3 years should generally not be tested for streptococcal tonsillitis unless specific risk factors exist (e.g., older sibling with documented infection), as the condition is uncommon in this age group and rheumatic fever risk is extremely low. 1, 2
Bottom Line
Cough excludes streptococcal tonsillitis as the primary diagnosis. 1 The presence of cough indicates viral infection, and pursuing streptococcal testing will result in overdiagnosis, unnecessary antibiotic prescriptions, increased healthcare costs, and contribution to antimicrobial resistance. 5 Treat symptomatically with antipyretics and analgesia. 4