A previously healthy 5-year-old boy is brought to the physician with 2 days of sore throat. He has some pain with swallowing but is drinking fluids normally. He also has fever but no rhinorrhea, cough, or congestion. The boy has no known allergies and his immunizations are up-to-date. He recently started kindergarten, and other children at the school have been ill. His temperature is 38.9 C (102 F), blood pressure is 110/60 mm Hg, pulse is 98/min, and respirations are 20/min. Physical examination shows purulent exudates on the tonsils and posterior pharynx. Anterior cervical nodes are enlarged and tender. Lungs are clear to auscultation. A rapid streptococcal antigen test result is positive. What is the best next step in management of this patient?

Question

A previously healthy 5-year-old boy is brought to the physician with 2 days of sore throat.  He has some pain with swallowing but is drinking fluids normally.  He also has fever but no rhinorrhea, cough, or congestion.  The boy has no known allergies and his immunizations are up-to-date.  He recently started kindergarten, and other children at the school have been ill.  His temperature is 38.9 C (102 F), blood pressure is 110/60 mm Hg, pulse is 98/min, and respirations are 20/min.  Physical examination shows purulent exudates on the tonsils and posterior pharynx.  Anterior cervical nodes are enlarged and tender.  Lungs are clear to auscultation.  A rapid streptococcal antigen test result is positive.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfb7_1568_8f63_4b3bd2afc5f5_MD0005_00 This patient's presentation of fever and sore throat without upper respiratory symptoms and his physical examination findings of tonsillar exudates and cervical lymphadenopathy are classic for streptococcal pharyngitis. Group A streptococcal (GAS) pharyngitis is most common in children age 5-15 and occurs in the late fall, winter, and early spring. Tonsillar exudates and tender anterior cervical lymph nodes are often seen on examination. Diagnosis should be confirmed with throat culture or rapid antigen testing prior to initiation of antibiotics. The rapid streptococcal antigen test (RSAT) is highly specific, and antibiotic treatment can be initiated after a positive test. However, due to the test's poor sensitivity, throat cultures must be obtained after all negative RSATs in children (Choice B). Throat cultures are not necessary if the RSAT is positive. Penicillin and amoxicillin are the first-line treatment options for patients with streptococcal pharyngitis, as these medications are safe, narrow spectrum, and cost-effective. The goals of treatment are to reduce symptom severity and duration, decrease spread to close contacts, and prevent acute rheumatic fever. (Choice A) Heterophile antibody testing (eg, Monospot) is used to identify infectious mononucleosis (IM) caused by the Epstein-Barr virus. IM is most common in adolescents and presents with fever; fatigue; exudative pharyngitis; and diffuse, posterior cervical lymphadenopathy. This patient's age, anterior cervical lymphadenopathy, and positive RSAT make IM unlikely. (Choice D) Broad spectrum antibiotics, such as amoxicillin-clavulanic acid, are not indicated as GAS is highly sensitive to penicillin and amoxicillin. Cephalosporins can be used to treat streptococcal pharyngitis in penicillin-allergic patients. Inappropriate prescription of these other antibiotics lead to emerging resistance of bacterial strains in general. (Choice E) Nonsteroidal anti-inflammatory medications and hydration are adequate for treatment of viral pharyngitis, which typically presents with upper respiratory symptoms (eg, rhinorrhea, cough). Symptomatic treatment serves as an adjunct to antibiotics in streptococcal pharyngitis. Educational objective: Streptococcal pharyngitis presents with fever, sore throat, tonsillar exudates, and tender anterior cervical lymphadenopathy. Because the rapid streptococcal antigen test is highly specific, treatment with penicillin or amoxicillin can be initiated after a positive test without a confirmatory throat culture. References: Rapid antigen detection testing in diagnosing group A beta-hemolytic streptococcal pharyngitis. (http://www.ncbi.nlm.nih.gov/pubmed/17009909) Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22048053)

A Previously Healthy 5-Year-Old Boy Is Brought to the Physician