What are the signs and symptoms of strep throat, particularly in children and adolescents?

Signs and Symptoms of Strep Throat

Strep throat typically presents with sudden onset of sore throat, fever, pain with swallowing, and absence of viral symptoms like cough or runny nose, most commonly affecting children aged 5-15 years. 1

Classic Clinical Presentation

The hallmark features that should raise suspicion for Group A Streptococcal (GAS) pharyngitis include:

Throat and Oral Findings:

• Tonsillopharyngeal erythema (redness) with or without patchy exudates 1, 2
• Palatal petechiae (small red spots on the roof of the mouth) 1, 2
• Beefy red, swollen uvula 2
• Intense inflammation of the tonsils and throat 3

Systemic Symptoms:

• Sudden onset of sore throat (not gradual) 1
• Fever (typically >100.4°F or 38°C) 1, 4
• Pain with swallowing (dysphagia) 1, 3
• Headache 1, 5
• Nausea, vomiting, and abdominal pain (especially common in children) 1, 2

Physical Examination Findings:

• Tender, enlarged anterior cervical lymph nodes (front of the neck) 1, 2
• Bilateral cervical lymphadenopathy 5, 6

Associated Findings:

• Scarlatiniform rash (sandpaper-like rash indicating scarlet fever) 1
• Peak occurrence in winter or early spring 1
• History of exposure to documented strep case 1

Age-Specific Considerations

Children and Adolescents (5-15 years):

• This is the primary age group affected by strep throat 1
• Classic presentation is most common in this population 3
• Only 20-30% present with all classic features 3

Children Under 3 Years:

• Strep throat is uncommon in this age group 1
• May present atypically with excoriated nares or purulent nasal discharge rather than classic pharyngitis 2
• Testing generally not recommended unless risk factors present (e.g., older sibling with strep) 1

Adults:

• Less common than in children (5-15% of adult sore throats) 5, 6
• May have less pronounced symptoms 7

Critical Distinguishing Features from Viral Pharyngitis

Features that SUGGEST VIRAL infection (NOT strep):

• Cough 1, 8
• Runny nose (coryza) 1, 8
• Hoarseness 1, 8
• Conjunctivitis (pink eye) 1, 8
• Discrete oral ulcers 1, 8
• Diarrhea 1
• Viral rash (exanthem) 1
• Gradual onset rather than sudden 8

Important Clinical Caveat

Even experienced physicians cannot reliably differentiate strep from viral pharyngitis based on clinical features alone 1, 8. The symptoms overlap significantly, which is why:

• Laboratory confirmation is mandatory before prescribing antibiotics 1
• Rapid antigen detection test (RADT) or throat culture should be performed 1
• In children and adolescents, negative RADT requires backup throat culture 1
• Do NOT test if obvious viral features are present (cough, runny nose, hoarseness) 1

Common Pitfalls to Avoid

• Overdiagnosis is extremely common: Physicians overdiagnose strep throat by a wide margin, leading to unnecessary antibiotic use 3
• Only 10% of adults with sore throat actually have strep, yet 60% receive antibiotics 7
• Carriers with viral infections: Some patients are asymptomatic GAS carriers who develop viral pharyngitis—they will test positive but don't need antibiotics for the viral illness 8
• Don't rely on presence of exudates alone: Exudates can occur with both viral and bacterial pharyngitis 1
• Even with all clinical features suggesting strep, only 35-50% of cases are actually GAS-positive 8

Modified Centor Criteria (Clinical Decision Tool)

The following scoring system helps determine who needs testing 1, 6:

• Fever by history (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical adenopathy (1 point)
• Absence of cough (1 point)

Score interpretation:

• <3 points: Testing generally not needed 1
• 2-3 points: Perform RADT 6
• The Centor criteria have low positive predictive value, so they're best used to identify who does NOT need testing 1