Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

Group A beta-hemolytic streptococci (Streptococcus pyogenes) are the most common bacterial cause of pharyngitis.


(see Chapter 8)


General Considerations

Group A streptococci producing erythrogenic toxin may cause scarlet fever in susceptible persons. Acute rheumatic fever may follow recurrent episodes of pharyngitis beginning 1–4 weeks after the onset of symptoms. Effectively controlling rheumatic fever depends on identification and treatment of primary streptococcal infection and secondary prevention of recurrences.

Glomerulonephritis is another rare complication, following a single infection with a nephritogenic strain of streptococcus group A (eg, types 4, 12, 2, 49, and 60), more commonly on the skin than in the throat, and begins 1–3 weeks after the onset of the infection.

Clinical Findings

S pyogenes (group A Streptococcus [GAS]) pharyngitis is usually a self-limited condition, lasting 3–5 days.

1. Scarlet fever

Scarlet fever may appear one or two days after the onset of GAS pharyngitis. The rash of scarlet fever (also called scarletina) is diffusely erythematous and resembles a sunburn, and superimposed fine red papules give the skin a sandpaper consistency; it is most intense in the groin and axillas (eFigure 33–1). It blanches on pressure, may become petechial, and fades in 2–5 days, leaving a fine desquamation. The face is flushed, with circumoral pallor, and the tongue is coated with enlarged red papillae (strawberry tongue). The diagnosis is clinical in the setting of streptococcal pharyngitis.

eFigure 33–1.

Scarlet fever. Skin lesions in the form of a blush from scarlet fever. The rash resembles a sunburn and is usually redder in the axillary and groin areas. (Public Health Image Library, CDC.)

2. Rheumatic fever

The diagnosis of acute rheumatic fever relies on a constellation of signs, symptoms, and laboratory findings, known as the Jones criteria: major criteria include presence of pancarditis, polyarthritis, subcutaneous nodules, erythema marginatum, chorea, and minor criteria include presence of heart block, arthralgia, elevated ESR or CRP, fever, leukocytosis, or history of prior rheumatic fever. At least two major Jones criteria or one major and two minor criteria plus evidence of recent GAS infection by either bacterial culture data, rapid strep testing, or elevated anti-strep antibody titers are required to establish a diagnosis. These complications are more common in children.


Antimicrobial therapy of pharyngitis may reduce the risk of complications (see Chapter 8). There is no additional treatment of scarlet fever or acute rheumatic fever beyond that of the underlying streptococcal pharyngitis.

Prevention of Recurrent Rheumatic Fever

Patients who have had rheumatic fever should be treated ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.