In a 5-year-old child with a temperature of 104 °F (40 °C) and sore throat, what evaluations and testing are indicated?

Evaluation of a 5-Year-Old with 104°F Fever and Sore Throat

This child requires microbiological testing with either a rapid antigen detection test (RADT) or throat culture to confirm Group A Streptococcal (GAS) pharyngitis before initiating antibiotics. 1

Why Testing is Mandatory

Clinical findings alone cannot reliably differentiate GAS pharyngitis from viral causes, even for experienced clinicians. 1 This 5-year-old falls squarely in the peak age range (5-15 years) for GAS pharyngitis, and the fever of 104°F is consistent with bacterial infection. 1 However, accurate microbiological confirmation is essential because:

• Viruses cause pharyngitis considerably more often than bacteria, even with high fever 1
• Appropriate antibiotic treatment prevents acute rheumatic fever in most cases, but only when GAS is truly present 1
• Overtreatment without confirmation promotes antibiotic resistance and unnecessary side effects 1

Specific Clinical Features to Assess

Examine this child for the following features that suggest GAS rather than viral etiology:

Features supporting GAS pharyngitis:

• Sudden onset of sore throat 1
• Pain on swallowing 1
• Tonsillopharyngeal erythema with or without exudates 1
• Tender, enlarged anterior cervical lymph nodes 1
• Soft palate petechiae or beefy red swollen uvula 1
• Scarlatiniform rash 1
• Headache, nausea, vomiting, or abdominal pain 1

Features suggesting viral cause (do NOT test if present):

• Coryza (runny nose) 1
• Cough 1
• Hoarseness 1
• Conjunctivitis 1
• Diarrhea 1

Testing Algorithm

If viral features are present: Do not perform GAS testing—this is a viral URI and requires only symptomatic management. 1

If viral features are absent: Proceed with testing:

1. Perform RADT immediately 1

   • If positive: Diagnostic for GAS pharyngitis—initiate antibiotics 1
   • If negative: Obtain backup throat culture (mandatory in children and adolescents) 1

2. Alternative approach: Use molecular testing (loop-mediated isothermal amplification) if available, which has 98.6% sensitivity versus 49.3% for RADT and 77.5% for culture 2

Treatment Once GAS is Confirmed

First-line therapy: Amoxicillin or penicillin for 10 days 1

• Penicillin V: Standard dosing for 10 days 1
• Amoxicillin: Once-daily dosing option available 1
• Alternative for penicillin allergy: First-generation cephalosporin, clindamycin, clarithromycin, or azithromycin 1

Benefits of treatment:

• Shortens symptom duration 1
• Prevents rheumatic fever 1
• Limits secondary transmission 1

Critical Pitfalls to Avoid

Do not treat empirically without testing. Even when all clinical criteria are present, empirical treatment without confirmation is not recommended except in rare circumstances (e.g., symptomatic household contact with confirmed GAS). 1 The colonization rate reaches 15-20% even among asymptomatic children, so positive tests without appropriate clinical criteria may represent carriers rather than acute infection. 1

Do not test children younger than 3 years unless specific risk factors exist (e.g., older sibling with GAS), because GAS rarely causes pharyngitis and rheumatic fever is uncommon in this age group. 1 However, this 5-year-old is in the appropriate age range for testing. 1

Do not use azithromycin or oral third-generation cephalosporins as first-line agents due to S. pneumoniae resistance concerns. 1

Additional Considerations for High Fever

With a temperature of 104°F, also assess for:

• Adequate hydration status 3
• Toxic appearance, respiratory distress, or altered consciousness requiring immediate intervention 4
• Tachycardia out of proportion to fever (may indicate pneumonia—obtain chest X-ray if present with cough or hypoxia) 4

Provide antipyretics (acetaminophen or ibuprofen) for comfort, but do not use response to antipyretics as an indicator of disease severity. 3