A Diagnostic Dilemma

Patient History
• A 28-year old male presents to the Emergency Department
(ED) with a one-day history of sore throat and fever.
• Upon examination, tonsillar swelling is noted without pus.
• A rapid antigen detection test (RADT) for Group A
Streptococcus (GAS) performed in the ED is negative.
• A throat swab is collected for culture.
• The patient is sent home with instructions for symptomatic
relief of a presumed viral pharyngitis.
• The next day the patient returns to the ED with worsening
sore throat and difficulty swallowing. Pus is now seen on the
tonsils and the uvula is deviated towards one side of his
throat.
 Microbial Causes of Acute Pharyngitis
• Viral (60%)
– Rhinovirus
– Adenovirus
– Coronavirus
– Epstein-Barr virus
– Other upper respiratory pathogens
• Bacterial (10-15%)
– Group A Streptococcus
– Group C and G Streptococcus
– Arcanobacterium haemolyticum
– Fusobacterium nucleatum
– Corynebacterium diptheriae
– Neisseria gonorrhea
– Others
• Non-infectious or Unknown (25%)
Photo Credits:
http://bioweb.uwlax.edu/bio203/s2009/weisser_mich/structure.html
http://www.gov.mb.ca/health/publichealth/diseases/gas.html
Processing of Throat Cultures for
Bacterial Pathogens

Throat swab is Plates

sent to the incubated
microbiology aerobically at
laboratory and 35°C for 24 to A trained microbiologist
plated to blood 48 hours examines the plates for common
agar bacterial causes of pharyngitis

Photo Credits:

http://en.wikipedia.org/wiki/File:Agarplate_redbloodcells_edit.jp
g
http://www.healthcentral.com/ency/408/imagepages/9950.html
 Laboratory Results
• The clinical microbiologist notes β-hemolytic colonies on
the blood agar plate after 24 hours incubation
• A Gram stain of a colony reveals Gram-positive cocci
growing in long chains
• The organism is catalase negative and susceptible to the
antibiotic/biochemical bacitracin

Photo Credits:
http://textbookofbacteriology.net/streptococcus.html
 Diagnosis

Peritonsillar abscess caused by Group

A Streptococcus (Streptococcus
pyogenes)

The final diagnosis could only be

made by performing throat
culture in the microbiology
laboratory since the rapid antigen
test result was falsely negative
 Potential Complications of
Group A Streptococcal Pharyngitis

Suppurative (pus) Non-Suppurative

Peritonsillar abscess Acute rheumatic fever
Lymphadenitis Acute glomerulonephritis
Sinusitis
Otitis Media
Mastoiditis
Invasive infections (e.g. toxic shock
syndrome, necrotizing fasciitis)
 Sensitivity of Diagnostic Tests for GAS
Pharyngitis
• RADT
– 55-85% sensitive1,2
• Throat Culture
– 95% sensitive3
• Lower sensitivity of RADT indicates false negative results
are not uncommon
• Reflexive culture of specimens with negative RADT results is
recommended for diagnosing GAS
• Since RADT is highly specific for GAS, specimens with
positive results do not need to be cultured
1 Uhl, JR., et al. 2003. J Clin Microbiol 41: 242-249.
2 Ruiz-Aragon, J., et al. 2010. Anales de Pediatria 72:391-402.
3 Bisno, AL. 2001. NEJM 344: 205-211.
 Patient Outcome
• Due to the false negative RADT, the patient was initially
sent home without antimicrobial treatment
• A throat culture performed by the microbiology laboratory
led to the diagnosis of Group A streptococcal pharyngitis
• Upon receipt of the culture results, the physician contacted
the patient for follow up
• The patient’s peritonsillar abscess was drained and the
patient was treated for 10 days with penicillin
• The patients symptoms completely resolved with this
course of treatment
Tanis C. Dingle, Ph.D, D(ABMM)
Dr. Dingle is an Associate Professor in the Department of
Pathology at the Icahn School of Medicine at Mount Sinai
and Co-Assistant Director of Microbiology for the Mount
Sinai Health System in New York City. Dr. Dingle is a
Diplomate of the American Board of Medical Microbiology
and trained in the CPEP program at the University of
Washington in Seattle. Her research interests include
antimicrobial resistance and the application of MALDI-TOF
mass spectrometry in the clinical microbiology laboratory.