What is the management of a patient with streptococcal (strep) pharyngitis and persistent myalgias, brain fog, and fatigue following multiple tick bites in Vermont?

From the Guidelines

For a patient with strep-positive acute pharyngitis and 2-3 weeks of myalgias, brain fog, fatigue, and multiple tick bites in Vermont, I recommend a two-pronged treatment approach. First, treat the strep pharyngitis with penicillin V potassium 500 mg orally twice daily for 10 days, as recommended by the Infectious Diseases Society of America 1. For penicillin-allergic patients, alternatives include cephalexin 500 mg four times daily for 10 days (if no anaphylaxis history) or azithromycin 500 mg on day 1 followed by 250 mg daily for 4 more days. Second, given the prolonged systemic symptoms and tick exposure in an endemic area, empiric treatment for possible tick-borne diseases is warranted. Doxycycline 100 mg twice daily for 10-21 days would cover Lyme disease, anaplasmosis, and ehrlichiosis, as recommended by the CDC 1. Testing should include Lyme disease serology (ELISA followed by Western blot if positive), complete blood count, comprehensive metabolic panel, and specific PCR tests for tick-borne pathogens if available. The patient should be monitored for symptom improvement, with follow-up in 1-2 weeks. This dual approach addresses the confirmed strep infection while acknowledging that the longer-duration systemic symptoms may represent a tick-borne illness, which is particularly concerning given the multiple tick exposures in Vermont, where Lyme disease and other tick-borne illnesses are endemic. Some key points to consider in the management of tick-borne diseases include:

• Doxycycline is the drug of choice for treatment of all tickborne rickettsial diseases in children and adults 1
• Delay in treatment of tickborne rickettsial diseases can lead to severe disease and death 1
• Prophylactic use of doxycycline after a tick bite is not recommended for the prevention of tickborne rickettsial diseases 1

From the FDA Drug Label

Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes)

Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS):

Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS

Day 14Day 30

Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%)

Penicillin V242/332 (73%)206/325 (63%)

Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%)

Penicillin V284/338 (84%)241/325 (74%)

The patient has strep positive pharyngitis, and the most appropriate management would be to treat with azithromycin (12 mg/kg once a day for 5 days) or penicillin V (250 mg three times a day for 10 days).

• Key considerations:
  • The patient's symptoms of myalgias, brain fog, fatigue may be related to the strep infection or another underlying condition, such as Lyme disease, given the history of multiple tick bites in Vermont.
  • However, the FDA label does not provide direct guidance on the management of these additional symptoms.
  • Azithromycin has been shown to be effective in treating strep pharyngitis, with a clinical success rate of 98% at Day 14 and 94% at Day 30.
  • The patient's 1 day of acute pharyngitis and 2-3 weeks of myalgias, brain fog, fatigue may require further evaluation and management beyond the treatment of strep pharyngitis alone 2.

From the Research

Management of Strep Positive Patient

• The patient has a positive strep test with 1 day of acute pharyngitis and 2-3 weeks of myalgias, brain fog, and fatigue, along with multiple tick bites in Vermont.
• The management of strep positive patients typically involves antibiotic treatment to alleviate symptoms, shorten the duration of illness, and prevent complications 3, 4, 5.
• Penicillin is the treatment of choice for strep throat due to its narrow spectrum of activity, effectiveness, and low cost 3.
• Alternative antibiotics such as amoxicillin, erythromycin, and first-generation cephalosporins can be used in patients with penicillin allergy 3, 4.
• The duration of antibiotic treatment is typically 10 days, and patients should complete a full 24 hours of antibiotics before returning to school or daycare 6.

Considerations for Tick Bites

• The patient's history of multiple tick bites in Vermont may increase the risk of tick-borne illnesses such as Lyme disease.
• However, the current evidence does not provide guidance on the management of strep positive patients with concurrent tick bites.

Clinical Guidelines and Diagnostic Methods

• Clinical guidelines for diagnosing and treating strep throat vary between professional associations, and there is no clearly superior management strategy 5.
• Diagnostic methods for strep throat include clinical scoring systems, rapid antigen detection tests, throat culture, and nucleic acid amplification tests 5.
• The choice of diagnostic method and antibiotic treatment should be based on individual patient factors and clinical judgment 4, 5.

Antibiotic Treatment Efficacy

• Studies have compared the efficacy of different antibiotics for treating strep throat, including penicillin, cephalosporins, macrolides, and azithromycin 4, 7.
• The evidence suggests that penicillin and amoxicillin are effective treatments for strep throat, while azithromycin may have lower bacteriologic eradication rates 4, 7.