Rapid Strep Test Positive But No Sore Throat

Occasionally, I see patients who have received throat swabs for strep that have come back positive... even if they have no signs or symptoms of pharyngitis.

In this situation, there are 2 main actions a physician may take (I am biased towards one):

1) Prescribe antibiotics until throat cultures are normal
2) Do nothing

Personally, if a patient is without throat symptoms and has no history of rheumatic fever or kidney damage, I would not have even bothered obtaining a strep test. What for???

Also, a person can be a carrier for strep without suffering any health problems. As such, even if the strep test is positive, but if the patient has no symptoms, I do not recommend treatment. (Which again begs the question of why bother getting a strep test if no treatment will be recommended regardless of the test result.)

I would go so far even to say follow-up cultures are NOT necessary after antibiotic treatment for strep throat if a patient does not have any more symptoms and exam is normal.

Which is why I find it surprising when children and adolescent patients receive multiple courses of antibiotics when they feel perfectly fine, but have received treatment just because a strep test came back positive.

Of course... that's just my opinion as I do acknowledge that there's another school of thought which supports antibiotic treatment of all strep positive cultures with follow-up cultures to ensure eradication.

However, according to the 2012 clinical practice guidelines published by the Infectious Diseases Society of America (statement 12),

"We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever; strong, moderate)."

Depending on the doctor you see, you will get different opinions. But it is good for patients to be aware of the varying views on this topic given how common sore throats are.

Reference:
Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. (2012) 55 (10): e86-e102. doi: 10.1093/cid/cis629

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Research on Sword Swallowing and Its Side Effects

Research has actually shown that sword-swallowing can cause sore throats! No kidding!

This particular research was based on 110 sword-swallowers from 16 different countries and was published in the British Medical Journal in 2006.

This research won the 2007 Ig Nobel Prize in Medicine. Watch a YouTube Video of a sword-swallower in action:



ENTs regularly perform a similar procedure when we perform "Direct Esophagoscopy". Just like a sword, it is an elongated rigid metal structure, except in the shape of a tube that we place through the mouth down towards the stomach. This procedure is used to look for mucosal lesions/masses (cancer) as well as retrieve foreign objects unable to pass. Gastroenterologists perform a similar procedure, but using a long flexible scope instead of a rigid scope. Some ENTs perform "Trans-Nasal Esophagoscopy" whereby instead of placing a flexible scope in the mouth (like the GIs do it) and threading down into the stomach, the scope is placed instead through the nose! Esophageal dilatation is another procedure similar to sword swallowing, but using stiff rubber in order to open up areas of narrowing in the esophagus.

Reference:
Sword swallowing and its side effects. BMJ 2006; 333 : 1285 doi: 10.1136/bmj.39027.676690.55 (Published 21 December 2006)

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Epiglottitis Killed President George Washington?

I came across a great blog post by Michael Hebert regarding a book review of Joseph Ellis' biography His Excellency: George Washington.

Apparently, at the age of 67, President George Washington died in 1799. I quote from the blog post the following account:

"One morning in mid-December 1799, Washington went out, as it was his daily habit, on horseback from his home to inspect his Mount Vernon property. That particular day the weather was very cold and there was an ice storm. It is said that Washington spent five hours out in freezing rain, then returned home and dined with guests in his wet clothes because he did not want to keep them waiting. The next day he complained of a sore throat and was hoarse, but otherwise appeared well. The following night he awakened Martha to tell her that he felt a severe pain in his throat, and was having trouble breathing.

The next day his personal physician, Dr. James Craik, was summoned. Craik diagnosed the condition as life threatening, and hastily assembled a team of doctors for aggressive treatment. They bled him of five pints of blood, burned his neck, and gave him calomel, a mercury compound used as a purgative but which probably did little more than induce mercury poisoning. Finally, after several days of this torture, Washington displayed the judgment that made him a great president and told them to stop. According to Ellis: “Eventually Washington ordered his doctors to cease their barbarisms and let him go in peace. ‘Doctor,’ he muttered, ‘I die hard, but I am not afraid to go” (p.269). He expired a few hours later."

According to the biographer, Pres. George Washington died of a serious childhood infection called epiglottitis which is an infection of the soft tissue flap (epiglottis) guarding the entrance of the voicebox. It is for which the Hib vaccine given to all kids now makes this type of infection a rarity (in fact, in my entire 10 year career so far as an ENT, I've seen only 3 cases so far).

However, I do agree with the blog article that epiglottitis is unlikely to be the actual cause for Pres. George Washington's sore throat and eventual death. Given his ripe age of 67, he would have developed natural immunity to the germ (Haemophilus influenzae type B) that causes epiglottitis and as such, it would be highly unusual (but not impossible) cause of infection and death. As the blogger stated, a more likely cause of the sore throat that eventually lead to his death is a peritonsillar abscess, a far more common cause of sore throats that could lead to death if not treated. Indeed, I see about 3-4 peritonsillar abscesses in my clinic per month during the winter season. It is also not unusual for a person to go from normal to developing a peritonsillar abscess within 1-2 days.

Ludwig's angina is the other possible culprit the blog post addressed which I also find unlikely. Ludwig's angina in essence is an infection of the submandibular salivary gland and would have presented with a huge swelling under the tongue and under the jawline (see picture to right)... two symptoms I would think that would have been documented in George Washington's history.

In any case, it is entirely possible that his physicians may have contributed to his death... blood-letting of 3.75 liters... Gosh... a human adult has about 5 liters of blood. As far as I'm concerned... that's medical malpractice and one could argue first degree murder. Add mercury poisoning as well.

You can purchase the biography of George Washington here.

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Washington Post Medical Mystery: Rare Severe Sore Throat Caused by Lemierre Syndrome

On Nov 3, 2009, the Washington Post Medical Mystery section published a story titled "Annoying bug turned out to be much more" where a 19 year old female presented with a sore throat which rapidly progressed to a blood clot in her jugular vein, pneumonia, and massive swelling in her neck.

What she ended up having was "Lemierre syndrome" suspected by the diagnosing doctor at Georgetown University Medical Center based on the two telltale symtoms of a jugular infection and presence of a blood clot.

Read the story here.

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