Strep carriers and the slippery slope

I was taught that being an asymptomatic carrier of strep in the throat was not associated with either illness or risk of complications. That’s not always true. The schedule said ‘strep throat x 5 weeks and diarrhea.’  Handing me the encounter form, my nurse warned me: ‘Mom’s not a happy camper.’

I remembered the child because of the unusual spelling of her name: Ribecka.  Reviewing my notes from their visit 5 weeks earlier, I had seen 8 year old Ribecka on call for one of my partners. She had come in with 5 days of runny and stuffy nose, moderate dry cough, hoarseness, headache and a bad sore throat. The nurse had already done a strep test at the mother’s request, because ‘strep was going around at school’ and it was positive. Ribecka had been afebrile and had a normal exam other than nasal congestion and I had told the mother that I thought her illness was viral.  I had explained that strep does not cause runny nose, hoarseness, or cough, and that her exam did not show anything suggestive of the kind of illness caused by strep. I had suggested liquids, rest and time. I encouraged them to call if she was not steadily improving or if she developed new symptoms. 

’Tell me what’s happened with Ribecka since I saw her,’ I asked.

The mother told me that Ribecka had continued to cough and complain about a bad sore throat and headache, so she had given her some antibiotics (Septra) left over from her older brother’s ear infection. Because she still had cough and sore throat despite four days of antibiotics, Ribecka’s parents had then taken her to the Emergency Room where her strep test was positive and she was treated with penicillin for 10 days. Because her cough still did not abate, she returned to the Emergency Room a second time where her strep test was still positive, and she was treated with amoxicillin-clavulanate (Augmentin). It was now about 5 weeks after her initial visit. Her sore throat had gradually gone away but she still had some mild cough. For the last week she had been having moderate diarrhea and abdominal cramps.

On exam, she as a well appearing child with no fever, had a normal looking throat, no adenopathy, a mildly tender abdomen, and a (+) strep test. The parents were concerned that her cough had not yet resolved and that her strep test remained positive despite 2+ courses of antibiotics and requested a referral to a pediatric infectious disease office to investigate for an immune deficiency. I explained that her illness was typical of a viral bronchitis and was nearing resolution, that the positive strep tests despite treatment in the absence of strep-like illness was characteristic of ‘carriers’ who had strep in their throat and were not sick, that there was no evidence for an immunity issue, but that I was pretty concerned that the diarrhea was a complication of her antibiotics. (In fact, her C. Diff testing was positive and she required treatment for this potentially very serious complication of antibiotic treatment.)

At their request, she was seen by the infectious disease specialist who did several hundred dollars of lab work that showed a normally functioning immune system and no evidence of recent streptococcal illness.  His letter to me (and to the family) confirmed my diagnosis of a healthy child with a viral bronchitis and complications of inappropriate antibiotic use.

Which would probably not have happened if the nurse had not done a strep test.  Or if the mother had not given her left over antibiotics. Or if the ED had not twice given her antibiotics she did not need. But the (+) strep test was the biggest problem. As the mother said when I saw them in follow-up: “But she had strep. I HAD to treat her.”

Never underestimate the power of noise to interfere with signal. 


 

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