Taking Chances With Strep Throat

A previously healthy 22-month-old male child presented in the summer to his pediatrician’s office with an acute febrile illness. Results of the physical examination were normal except for rhinorrhea, but because of the fever, the pediatrician performed a rapid antigen strep test. The test result was positive, and 10 days of amoxicillin/clavulanic acid were prescribed. After 7 days on the antibiotic, the patient developed a diffuse, erythematous rash on his trunk and extremities; he was taken to the emergency department, where he was prescribed oral steroids for the rash. The following morning, his pediatrician diagnosed the rash as a drug reaction and discontinued the amoxicillin/clavulanic acid and started azithromycin to complete the treatment course for group A streptococcus (GAS) pharyngitis or “strep throat.” The following day, the patient’s rash became more widespread and pruritic. A third visit with the pediatrician was scheduled, and erythema multiforme was diagnosed. The patient was nontoxic appearing, but the pediatrician decided to admit him to complete the treatment course for strep throat along with possible intravenous steroids as therapy for the erythema multiforme. On admission, the patient was noted to have an impressive rash without oral or ocular involvement and was otherwise well-appearing. Ultimately, a tactful discussion with the admitting pediatrician revealed that the preferred course for all parties would be discontinuation of antibiotics and steroids, and the patient was then discharged from the hospital.

In the practice of medicine, we should attempt to weigh the risks and benefits of each patient management decision. This particular case brings up various opportunities in which decisions might have been made differently if both the potential risks and benefits of the treatment were considered more explicitly. First, what were the chances that this child had strep throat? A positive rapid strep test result may indicate true infection or …