Symptoms of Strep Throat
Strep throat typically presents with sudden onset of severe sore throat, fever above 100.4°F (38°C), tonsillar exudates, and tender enlarged anterior cervical lymph nodes—but the absence of cough, runny nose, conjunctivitis, or hoarseness is equally important, as these viral features argue strongly against bacterial infection. 1, 2
Classic Throat and Oral Findings
- Tonsillopharyngeal erythema (redness and inflammation of the throat and tonsils) is the hallmark finding in streptococcal pharyngitis 1, 3
- Patchy tonsillar exudates (white or yellow patches on the tonsils) may be present but are not required for diagnosis 1, 3
- Palatal petechiae ("doughnut lesions"—small red spots on the roof of the mouth) are highly suggestive of strep throat when present 1, 2
- Beefy red, swollen uvula is another characteristic finding 1, 2
- Oral malodor (bad breath) may be present 4
Lymph Node and Systemic Findings
- Tender, enlarged anterior cervical lymph nodes (swollen, painful glands in the front of the neck) are commonly found 1, 3, 5
- Fever typically ranging from high to very high body temperature (>100.4°F or 38°C, often >38.5°C) 1, 3, 5
- Sudden onset of symptoms is characteristic, rather than gradual progression 6, 5
- Severe sore throat that is worse with swallowing 7, 5
- Chills are commonly reported 5, 4
- Headache is frequently present 1, 5
- Malaise (general feeling of being unwell) 5
Gastrointestinal Symptoms (Especially in Children)
- Nausea, vomiting, and abdominal pain may occur, particularly in children 1, 5
- These gastrointestinal symptoms can be prominent enough to confuse the clinical picture, but they occur alongside throat findings 1
Critical Distinguishing Features: What Strep Throat Does NOT Cause
The presence of any of these features strongly suggests viral pharyngitis rather than strep throat, and testing for strep is not recommended when these are present: 7, 6, 2
- Cough argues against bacterial infection 7, 6, 3, 5
- Runny nose (coryza/rhinorrhea) suggests viral etiology 7, 6, 3, 4
- Conjunctivitis (pink eye) indicates viral cause 7, 1, 6
- Hoarseness suggests viral pharyngitis 7, 1, 6
- Discrete oral ulcers (mouth sores) indicate viral infection 1, 6
- Diarrhea is more common with viral causes 3, 5
Age-Related Considerations
- Strep throat primarily affects children between 5 and 15 years of age, with 15-35% of pediatric pharyngitis cases being streptococcal 1, 8
- In adults, only about 5-15% of pharyngitis cases are due to strep, and symptoms may differ from pediatric presentations 4, 8
- In children younger than 3 years, classic findings may be less apparent, and strep may present with purulent nasal discharge and excoriated nares rather than typical pharyngitis 1
Diagnostic Caveat
Even experienced clinicians cannot reliably distinguish streptococcal from viral pharyngitis based solely on physical examination—microbiological confirmation with rapid antigen detection test (RADT) or throat culture is mandatory for diagnosis. 1, 6, 2 Clinical findings have high sensitivity but low specificity, meaning that while most strep throat patients will have these symptoms, many patients with these symptoms will have viral infections instead 4.
When to Suspect Strep and Test
Test for strep when a patient presents with:
- Sore throat AND fever AND absence of viral features (no cough, runny nose, conjunctivitis, or hoarseness) 6, 2
- Age 3-15 years with compatible symptoms 1
- Winter or early spring presentation in temperate climates 7, 1
- Known exposure to a documented strep case 1
Do not test if obvious viral features are present, as this leads to unnecessary antibiotic use 7, 2.