To the Editor: Jeffrey Tiemstra and Rosita L. F. Miranda1 have added important data concerning the diagnosis and management of acute pharyngitis. Like previous investigators, they found that a significant percentage of adolescents and young adults presenting with acute pharyngitis grow streptococci from a group other than group A strep, which is the classic concern.
Most other articles on this subject have focused on group C and group G streptococci. I doubt that clinical presentation of group B resembles the clinical presentation of group C. In unpublished data, we did not find group B patients having such a presentation. Zwart also found that only A, C, and G caused pharyngitis.2 Therefore, I would suggest that the authors look carefully at the distribution of clinical indicators in group B compared with group A and group C.
The Tiemstra article also shows that in practice (rather than in prospective studies) the sensitivity of the group A strep rapid test was only 75%. One can postulate several reasons for a difference in rapid test sensitivity from prospective studies. Just to suggest 2 possibilities: (1) sampling errors might occur more often in practice or (2) there may be publication bias for higher sensitivity studies.3
Like Zwart's classic 2000 BMJ study on treatment, the authors find a high probability of either group A or non-group A strep in patients having high pharyngitis scores.3 That article supports a clinical improvement from antibiotics for group C strep pharyngitis. In that article adults (ages 15–60) experienced a 2-day symptom improvement if they had group A pharyngitis and a 1-day symptom improvement if they had group C pharyngitis.
The addition of headache to the pharyngitis scores, although understandable, makes comparison of this study to previous studies more difficult.
A note of caution: these findings probably apply to the adolescent/young adult age group and not pre-adolescents. Previous studies have shown that non-group A infections occur commonly in college health populations but not pre-adolescents.
Congratulations for continuing the documentation that adolescent and adult pharyngitis is more complex than deciding whether the patient has group A strep.
Notes
The above letter was referred to the author of the article in question, who offers the following reply.
