A Diagnostic Dilemma

Tanis C. Dingle, Ph.D, D(ABMM)

Icahn School of Medicine at Mount Sinai
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: Centers for Disease Control and Prevention and Flickr (NIAID)
 Processing of Throat Cultures for
Bacterial Pathogens

Throat swab is sent

to the microbiology Plates incubated
laboratory and aerobically at 35°C for
plated to blood agar 24 to 48 hours
Throat is swabbed in the area of the tonsils

A trained microbiologist examines the plates

for common bacterial causes of pharyngitis

Photo Credits: WIkimedia, Wikimedia, Wikimedia

 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 Credit: Centers for Disease Control and Prevention

 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.

Photo Credit: Wikimedia

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
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.

Photo Provided by Tanis Dingle, Ph.D., D(ABMM)