At least in our corner of the world, North East Ohio, we are experiencing levels of strep infection we have never seen before. For me that covers a 40 year span of practice and observation. So many families are telling us their day care center, schools, teams are seeing huge numbers of strep throat cases, infants are getting strep (see below for why that is odd), and many parents who never had strep before are getting strep.
What is going on? To address this astounding development, let’s take a step back and talk about what is strep, what it does, how the current patterns are way off the norm, and then speculate a bit about why. I say speculate because no one yet knows really why this is happening.
What is Strep?
The word strep refers to a very specific germ, a bacteria, and it also refers to the range of illnesses this one bacteria can cause.
The formal name of the bacteria is Streptococcus pyogenes. The word streptococcus describes what this bacteria looks like under a microscope. All the bacteria that have the suffix –coccus in their name appear like spheres, or beads, after the Greek word for berry, kokkos. And the strepto- part of the word comes from the Greek word streptos which means twisted. This is because all the Streptococcus bacteria look like a string of beads that is twisted. There are many species of the Streptococcus bacteria, this one is called pyogenes because it often cause fever, and you may sense that pyogenes is reminiscent of the words that refer to fire, like pyromaniac or funeral pyre. Literally pyogenes means, causes heat or fire.
Now, another way we classify the many Streptococcus species is by Groups defined by how they grow in a lab. Many people have heard of Group B strep, this is the species that dwells around our genitalia and can cause illness to a delivering Mom and delivered newborn. This is the one screened for in pregnancy. As you might suspect if there is a Group B for strep, there must be a Group A, and there is, as well as Group C, D, E, F, G, etc.
Our Streptococcus of interest, the pyogenes species, is the strep germ in Group A, so sometimes it is called Group A Streptococcus.
No matter how we refer to this species we are interested in here, Streptococcus pyogenes, Group A strep, it is this bacteria we are referring to when we say someone has strep.
What Does Strep Do?
This is a very prominent germ, as it has caused skin and throat infection, and worse, for thousands of years. Some bacteria that infect us and make pus live mostly in the gut, but this is one of those germs that prefer to live where their is more air, on our open skin, in our noses, in our throats and such. The other group of bacteria that also live there is called Staphylococcus aureus, or staph. Together, staph and strep cause most human skin infections, as well as abscesses of the skin, but these germs can infect even deeper tissues, and cause serious bacterial pneumonias, meningitis.
In all these infections, what the strep germ does is literally eat the cells it invades, and in the process the immune system tries to fight back, together creating masses of bacterial waste, piles of dead bacteria and white blood cells, a white goop called pus. So strep eats cells and makes pus.
But in almost everyone’s life, the main troubles strep cause are strep throat and skin infections, and their complications. We won’t talk much about skin infections, but if you see your child have a redness develop around their nose or lips, that gets crusty and red bumps start spreading, or if a red area with crusting begins to swell and ooze pus, then staph or strep are almost always the cause.
Now, here our focus will be on the strep infection that has exploded into our lives, the strep throat.
What is Strep Throat?
Strep throat happens when the strep germ, the Streptococcus pyogenes, gets into the actual tissue of the throat, starts eating the tissue, that is infect the throat.
When this germ infects the throat the possible problems that causes are a wide range. Massive studies of strep throat in the 1950’s and 1960’s when a severe complication of strep throat was common (rheumatic fever, see below) and a treatment available to prevent it. In those days, if someone in the family had strep, everyone got a throat culture, so we learned the answer to the question, if 99 people get strep throat, how many have what symptoms.
Here is the pattern that has been observed for many decades:
If 99 people get strep throat-
- 33 will have no symptoms
- 33 will have a cold with no other symptoms
- 33 will have a cold andsore throat
This pattern should now be familiar. COVID is an infection we have all learned a lot about, and we learned that out of 100 people infected with COVID, 50 have no symptoms, similar to the 33% who have no symptoms when infected with strep throat.
This pattern also means that if every child, and every person, in America who got a sore throat saw a doctor and got tested for strep, we would miss 66% of all cases of strep throat. Even if we tested every child with any cold symptoms and sore throat, we would still miss 33% of strep throat cases. This basic fact about strep plays out when we discuss what happens to people who have had strep, see below.
Now the fact that 33% of people with strep throat feel fine DOES NOT mean that 33% of those who feel fine have strep throat. In fact, let’s turn around that last group, the group with sore throat. By turning it around I mean, instead of starting with 99 people known to have strep throat and asking what percentage of them have what symptoms, we turn it around and say, take 100 people with a symptom and what is the chance they have strep?
So, now take 100 people with fever, sore throat, cold symptoms, what is the chance they will have strep throat? You might think it’s very high, but it is not, the answer over many, many years has been 30%. That is, even a little less than a third of people with all the symptoms of classic symptomatic strep throat have strep. That is because cold viruses cause exactly the same symptoms as strep throat, and typically about 70% of kids with sore throat and fever have a viral infection, not a strep infection called strep throat. That number, I strongly suspect is different this year. We have found that of the kids we tested who had a sore throat and were ill, far more than 30% turned out to be positive for strep, some days that proportion was about 80% (!) of those tested were positive.
Do the turn around for the group with no symptoms and you will find the percent with strep dropping to close to zero. In fact, chances are that if you took a random group of 100 kids with no symptoms at all, feeling fine, you could very well find everyone’s throat swab would be negative for strep.
So, IF you have strep throat, THEN you have a 33% of feeling fine, 33% chance of having a cold, and 33% chance of having a cold and sore throat.
But that is NOT what we are asked when you bring your child to us to be seen. You ask, and we join you in asking, given this child with their symptoms, what is the chance they have strep? And that chance if you have a sore throat has gone up very dramatically this winter, as noted above.
What can Strep Throat Do?
As noted above, for a lot of kids, it does nothing. A full third have no symptoms, no problems at all.
But for about 2/3 of kids they do get sick. For 1/3 of all with strep the infection causes mostly cold symptoms of fever, cough and runny nose.
But 1/3 of kids who get strep throat get a sore throat. If you are a child, the sore throat hurts and can hurt a lot, but may be mild pain. If you get strep throat as an adult, the sore throat can be severe. Many parents have told me it was the worst pain of their life, many women have shared it was sharper pain than delivery.
Sometimes kids with strep throat get a rash. The rash is unique to strep throat, and consists of fairly fine red dots that once they coalesce feel like sandpaper. Strep throat with a rash is the definition of scarlet fever. For reasons explained below, scarlet fever used to be a very dread disease, but now it is simply strep throat with a rash, no more or less serious than plain strep throat.
Some kids with strep throat get a very characteristic rash on the roof of their mouth, their hard and soft palate. This rash looks like very bright red dots, that can be a set of single very tiny dots, or the dots can actually coalesce into a patch of very red, very angry looking area of the palate. Viruses can cause this rash too, but if you see this rash on the palate, called palatal petechiae, strep becomes very likely.
Rare and Serious Complications of Strep Throat
It turns out that Streptococcus pyogenes, the germ of strep throat, can sometimes cover itself with proteins that look just like proteins on specific parts of our body. And if the germ does this, when our immune system creates a ton of antibody and white cells to destroy the invading strep germ, those antibodies and white cells attack the cells of our body that have those proteins.
Fortunately, very fortunately, this happens far less often than it used to. Three organs were once more commonly attacked with strep throat, the kidney, the heart, and the brain. Let’s look at each for each have their very own story to tell.
Strep and the Kidney
This is a cross-reaction that is now quite rare in the developed world. But several decades ago, there were occasions when someone with strep throat would suffer serious kidney inflammation because the strep germ carried proteins on it that looked just like proteins on the cells of the kidney that form the filters that make it work. And as noted, when their body created antibodies to destroy the infection, they attacked their kidneys too. This reaction sparked at the time of the initial strep throat, so treatment could not prevent this from happening. We are all so fortunate that the strep germ close to no longer carries this cross-reactive protein, at least in developed nations. It was once a terrible problem that came with strep throat, and strep skin infections, and one that diagnosis and treatment could not prevent.
Strep and the Heart
Perhaps the most famous serious complication from strep throat has been rheumatic fever. Like the kidney complication, this once far more common threat has essentially vanished from developed nations. Before its decline here in the United States, fully 3% of all cases of strep throat led to rheumatic fever. That is, 3% of those with strep throat who had symptoms of a sore throat, 3% of all with strep throat who just had cold symptoms, and even 3% of all those with strep throat with no symptoms at all.
Rheumatic fever happens when the strep germ carries a set of proteins on it that look just like proteins in several parts of the body- the brain, the heart, the joints, and the skin, to list some main parts. During the heyday of rheumatic fever, which still happens quite a bit in the poorer nations of our planet, about 3% of a nation would see terrible diseases of the heart, brain, joints, and skin erupt over 10 days past
the strep throat, even if the child never got sick at all. The attacks of rheumatic fever on the heart would lead to permanent damage to a person’s heart valves, dooming millions to heart failure over time.
During World War II, the discovery was made that treatment with penicillin within 10 days of onset of strep throat would fully prevent all the harms from rheumatic fever. The amazing finding was that you could start penicillin on the 9th, even the 10th day after the strep throat infection began, and you would eliminate the risk of terrible heart damage, arthritis, skin nodules, and terrible neurologic reactions from the reaction to the strep infection called rheumatic fever. This discovery ushered in an era we still live in, when families would seek a strep test to see if their child’s sore throat was strep, knowing they had only 10 days to avoid possible catastrophe. Back when rheumatic fever showed up in 3% of all strep throat cases, doctors would do a throat culture on everyone in the family when one child came back positive, knowing the risk of the tragedy of rheumatic fever was the same for their child with strep and a sore throat, and their child who looked fine but had strep, and even the parents who felt fine but had strep.
For reasons we do not know for sure, the 3% risk of rheumatic fever began to decline sharply in the US sometime in the 1970’s, to the point people began to ask, if rheumatic fever gets rare enough, do we need to treat strep anymore? Then in the early 1980’s or so, a few very localized outbreaks of rheumatic fever popped up, one was here in Akron, Ohio. That pushed us all to stop asking this question. But since then rheumatic fever has indeed essentially disappeared from the US, it is very, very, very rarely seen. I have never seen a case in my 38 years of pediatric practice.
Why has it disappeared here? It is not because of antibiotics, because as we noted even under the most aggressive pursuit of testing every child with a sore throat, we will still miss at least 2/3 of all strep cases, the ones where the person has no symptoms and feels fine or has a bit of a cold with no sore throat.
If antibiotics didn’t quash rheumatic fever, what did? My own favorite hunch is based on the amazing fact that just like us, bacteria get viral infections too, and it looks like many of the meddlesome substances that cause the worst reactions in strep happen when the strep germ is infected with a virus. We know the proteins that irritate our skin and cause the rash of scarlet fever are seen only in strep germs that are infected with virus(es). The same is so for rheumatic fever, so it is very reasonable to posit that sometime, in the 1970s and 1980s, the virus that infected the strep germ stopped doing so, leaving the germ unable to spark the reactions we call rheumatic fever.
The reason this story is so important today even though rheumatic fever is now gone here, is that if the strep germ and its viral infections can shift away from rheumatic fever in the 1970-80’s, both could shift to create more reactions anytime in the future. We have some indicators that has been happening, which we turn to now.
Strep and the Brain
As noted, the wide range of terrible reactions strep throat provokes in rheumatic fever included a very characteristic set of neurologic reactions called Sydenham’s chorea, a terrible condition when typically all 4 limbs begin flailing in explosive motions, not in synchrony, with writhing, and often very distorted facial movements. This horrible condition can be mild with just some mild muscle writhing and twitching, or completely incapacitating. With the nearly complete disappearance of rheumatic fever, has come the nearly complete disappearance of Sydneham’s chorea.
But again, sometime in the last quarter of the 20th century, parents and some doctors began noticing their kids would develop tics on having strep throat. Sometimes the pattern was dramatic, and went beyond tics to include impulsive behaviors, and more severe movement disorders. They would explode on the child’s life when a strep infection hit, clear when placed on antibiotic, and even recur if antibiotics were stopped even some months after the strep throat.
Now when it comes to Sydenham’s chorea, there is no doubt that the cause is a protein carried by some strep germs that looks just like very specific and proven proteins in the brain. As such this chorea is a proven case of a germ sparking an unwanted, autoimmune attack on the brain. It is indeed a pediatric autoimmune neuropsychiatric disorder associated with streptococcal throat infections. Some may recognize this phrase and if you take some of the first letters in the phrase you get an acronym, PANDAS.
For many, many families who have seen their children develop severe movement and behavioral and psychiatric disorders in sync with having strep throat, there is a form of PANDAS that still happens, even though rheumatic fever has nearly vanished in the US. When it comes to this non-rheumatic fever PANDAS, the proof of a protein on a strep germ looking like a proven protein in the brain still is lacking, but the patterns are there. I have seen these patterns, including near cessation of all neurologic troubles with a daily dose of penicillin.
But at this time the PANDAS story in America today remains controversial, with some scientists thinking the very real appearance of these neurologic troubles is coincidental to having strep, arguing that so many children get strep throat, it will happen by chance that some with neurologic condition will see onset with a strep throat. But other groups of scientists believe the pattern of recurrence of neurologic symptoms with each strep throat and clearance of symptoms with antibiotic, and the known ability of strep to cross react in rheumatic fever, is good enough evidence there is a cross- reaction between strep and the brain happening even today.
I lean towards those that see strep throat causing neurologic movement, behavior, and psychiatric disorders, I have seen the pattern. Fortunately this bad impact from strep throat remains rare. We see strep throat every day, but have only seen a handful of PANDAS cases over the years, to put it all into perspective.
Prior to the COVID Pandemic, strep had a very regular level of activity. We very rarely saw anyone under age 2 have a strep throat. And most parents reported never having it as adults, some did, but not many. As noted above across the nation and across many decades, about 70% of kids we tested for strep who had terrible sore throats did not have strep, but were infected with various viruses including mono which causes the most severe of all sore throats.
But starting sometime this winter a striking explosion of strep was obviously happening. This was not just a wave of strep, but a true epidemic of it. We have heard from other pediatricians the same observation. To be sure, I have seen no actual epidemiologic data on this, so it all could just be a set of observations in local offices and not a true wave. But if what we are seeing represent a true trend, then we are living through a very dramatic outbreak of strep.
If so, and I repeat if so, this very strange explosion of strep becomes part of a pattern of epidemics that are simply weird, and out of joint.
Readers of Real Answers may recall during the COVID Pandemic that 2 winters ago the world experienced a striking absence of influenza epidemics. The annual influenza epidemic is a fixture in every nation on Earth. Here in the US it has shown up in full fury every December to May, always appearing around mid-December, raging away until sometime in April and May. But in the winter of 2020-2022, there was no influenza epidemic, not here, not anywhere. Then last winter it reappeared right on time, but unusually mild. This year is showed up in the US 2 months early! The epidemic was in full force in October and faded when it almost always used to peak, around January. Very, very strange. RSV is another cold virus that has always been highly seasonal, appearing every fall and winter. But 2 summers ago the RSV epidemics hit the US in the summer, unique, strange, way out of phase.
And so one has to wonder, why are all the cold and flu germs out of their normal tracks? Some say it’s because of all the lockdowns and masks, and that could be. In March 2020 we stayed home for many months, and that summer and winter not only was there no influenza epidemic, but there were no colds, and no strep. All came roaring back after we went back to school, but many of them returned while masked and distanced.
One other thought that I’ve had is that not only do germs push us around, but they push each other around. It stands to reason that over the millenia, strep, RSV, influenza, and many other germs have found a balance with each other, this germ spreads this month, that one that month. This one bursts into brief but intense outbreak, that one simmers always there in the background. Then along comes COVID and makes everyone infected with an altogether new germ, disrupting the balance and timing of all the others. This again, is just a thought, but I am thinking about it.
Whatever the reason, I fervently hope the strepidemic ends soon and never returns. I really worry that such out of joint outbreaks risk the strep germ changing again, acquiring a new viral infection of its own, or changing the basic germ, which could cause its proteins to once more shift and cause some new immune reaction syndromes, let us hope not, but we are watching.
Treating Strep Throat
As noted above, the main reason to urge treatment of strep throat is gone, at least in the developed world including the US, rheumatic fever is too rare to require everyone to be treated. Again, as noted, even the most intense program to treat all strep throats will miss at least 2/3 of the cases, since 1/3 have no symptoms, and 1/3 have colds with no sore throats, groups we never routinely test for strep. And so we know, that in our current reality in which about 2/3 of kids with strep throat do not get treated, they all do fine, no complications are seen with any worrisome frequency.
So why treat?
The main reason to treat strep throat is to ease the pain and discomfort, to cure the illness. So if your child is sick with a sore throat, testing for strep makes sense, because if we find it we can cure it and end the illness quickly.
The Strep Carrier
We don’t hear much about the phenomenon of the strep carrier much anymore, but sometimes we get asked so here is what this is. A person is a strep carrier if they have strep germs in their saliva and mucus, but not tissue. That is, the strep rides on the surface of their tissue but is not infecting. The carrier cannot spread strep as they are not infected and carriage cannot spread. So why even talk about it? The problem with strep carriage is on us, as it messes up our testing. Strep in the saliva will make a strep test positive even if you have no infection. So it makes testing sort of useless, but it causes no harm to the carrier or those in contact with the carrier. If a child is always strep positive, the only way to distinguish carrier from infected is with two blood tests 2 weeks apart, each testing for antibody to strep and seeing if it goes up. For the carrier who has no infection, the antibody does not go up, for the infected it does.
- Who hasn’t heard of strep throat? It is one of the most common, most familiar of childhood, and even adult, infections.
- Strep throat is caused by one and only one germ, the strep germ, formally named Streptococcus pyogenes.
- This germ infects by getting into our skin or throat and eating those cells, and in the process creating pus.
- There is no immunity to strep, you can get it any number of times, typically not before 2 years of age (until this strepidemic) and less likely once an adult (again, until this strepidemic).
- Strep throat can cause a very painful sore throat with fever, but 1/3 of everyone with it has no symptoms, and 1/3 have a cold with no sore throat. Turn the question the other direction, and you find that almost no one who feels well has strep throat, and only 30% of those with a fever and sore throat have strep (until this strepidemic).
- Plain old strep throat with a rash is scarlet fever, which is no more dangerous than strep throat without a rash. Both are easily cured with antibiotic.
- Over the ages the strep germ has mutated and also had different viral infections of its own. At times those changes move the germ to make proteins that look like ours. If the proteins look like proteins on our kidney cells, the strep infection can cause an inflammation of the kidneys. If the look alike is with the heart it can cause inflammatory damage to our heart valves, that is rheumatic fever. Rheumatic fever also used to involve damage to joints, skin, and brain too. Fortunately all these reactions are very, very rare in the US today.
- Some children today though experience onset of tics, psychiatric and behavioral problems just when infected with strep, that ease with antibiotic therapy. This pattern is reminiscent of the neurologic troubles seen in rheumatic fever, but no longer involves the heart or other organs. Not everyone accepts this pattern occurs, but I’ve seen it and believe it. It goes by the name PANDAS.
- This winter we saw an explosion of strep throat the likes of which we have never seen. If that pattern is nationwide we will have been enduring a striking strep epidemic, what I call a strepdemic. Time will tell if that is what has happened, but from the vantage point of our office it sure seems like it did. No one knows why, and we hope the tons of strep throat do not lead to changes that bring back more immune reactions to strep throat.
- With kidney reactions and rheumatic fever nearly gone, why treat strep? The main reason is to end the disease and its misery of a painful throat.
- Finally a word on the strep carrier. This is the state where a person has live strep germs in their saliva, but is not infected, not contagious. It makes all strep swab tests positive though not infected, but causes no harm to the person.
Strep throat touches everyone, we hope this review helps understand it!
To your health,
Dr. Arthur Lavin
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