The Sore Throat. Is it a Virus or Strep?

Wondering if your sore throat is viral or strep? This is a common question. Compare them below to see where you stand.

Colds and Viruses Often Cause a Sore Throat

Often, a virus gets into your throat when you have a cold. When the throat tries to fight off these irritants, it becomes inflamed and sometimes very sore. A day or two later, after the sore throat comes on, cold symptoms arise: Your nose starts to run, and clear/cloudy, watery mucus goes down your throat (postnasal drainage). This mucus is acidic can irritate your throat even more, causing even more inflammation and pain. This is very common. Note: The sore throat usually comes on before the cold symptoms appear.

A Sore Throat

Many times, people go to their healthcare providers with a sore throat, thinking they have strep when, in fact, the sore throat is the very beginning of a viral cold. A cold can cause several problems with the throat: Sometimes it is just local viral irritation, but other times, it is due to postnasal drainage traveling down the throat from the sinus, which causes even more irritation and pain. The throat pain tends to become worse when a person lies down or during sleep. This is one of the reasons a sore throat is worse in the morning. Furthermore, postnasal drainage may cause frequent throat clearing, compounding the problem. Many people are unaware that they are throat-clearing (I have heard people clear their throats maybe 10 times in 20 minutes, and they are not even aware that they are doing it!). A day or two later, the sore throat disappears, and the person has a full-blown cold. This OFTEN explains the horrible sore throat and negative strep test.

Antibiotics are not typically used for these cold symptoms because they are almost always viral, and antibiotics do not kill or stop viral replication. However, if the illness is ONGOING (greater than seven to ten days), it may have become a sinus infection, in which case an antibiotic may be warranted.   

Structures of the Throat: Uvula and Tonsils

The Throat-------->

Strep seems to be of great concern to many patients. Let's look at this.

FACT: According to Science Daily, about 15 million people are seen in doctors' offices, ERs, and clinics every year complaining of a sore throat (pharyngitis).

FACT: According to studies, about 90% of sore throats are viral. Only about 5 to 15% of adults tested have strep—that would be 1 in 10 people—and anywhere from 15 to 30% of children tested for strep are positive. 

FACT: In the past, people used to get antibiotics for any kind of sore throat, even though they did not need them. 

How Can You Determine What Is Causing The Sore Throat. Is it a Virus or Strep?

First, Compare Common Symptoms

Besides viruses, bacteria can also get into your throat. People are particularly concerned about strep because it can cause more than just a transient sore throat. These are discussed below.

FREQUENT SYMPTOMS OF STREP

• Sore throat and...

• Fever - A sore throat, with a fever >101 is often strep.

• Enlarged Lymph Nodes (below the jaw on the sides)- Often a sign of strep when accompanied by a fever and sore throat

• White patches or exudates on tonsils - But be aware, these exudates can also be - and often are - viral. If you have spots or the white area has a "chunky" appearance, it may be tonsillar stones with no other symptoms except a sore throat. It is common for patients to mistake tonsillar stones for strep.

LESS COMMON SYMPTOMS OF STREP   

• Excessive fatigue - low energy/tiredness in kids and adults

• Big BAD red tonsils - May be strep but usually accompanied by sore throat, fever, enlarged lymph nodes if strep

• Nausea and vomiting - Especially in kids. Typically not accompanied by diarrhea 

• Body aches - Along with sore throat, adults sometimes feel "fluish" but usually without runny nose or cough. 

• Halitosis is bad breath accompanied by a sore throat and other symptoms. (This can also be a bad tooth or sinus infection.)

• Body Rash—If this occurs, it is usually in children. Typically, it occurs with other strep symptoms. This is often called scarlet fever (but it is not as scary as it sounds).   

• Throat Rash: Pinpoint red diffuse rash in the back of the throat and soft palate.        

• Dark circles under the eyes - "Racoon eyes" - also occur with allergies.

• Headaches - Sometimes accompanies strep.

• Ear Pain - Usually comes from referred throat pain.

Unless you know you have been in very close contact with someone infected with strep, an early sore throat or a sore throat with other symptoms (cough, runny nose) is USUALLY NOT strep. It is best to wait a couple of days before being tested unless the sore throat is severe or you are concerned that other people might catch it. In the meantime keep some distance from others so you will not spread whatever you have.

Exposure - If you have been exposed to strep but you don't have symptoms, you likely do not have strep yet – Incubation time is one to three days. It is best to wait until you get symptoms before you go to get tested. Remember: It takes direct contact: Maybe a kiss, sharing a glass, a cough right in your face. If you haven't had exposure to kids or crowds (i.e., at home, school, or church), it's likely not strep. I often hear this: "Someone in my office had strep, and I think I might have it now." If you did not get very close to that person, use the same drinking fountain or share something with that person, it is extremely unlikely that you have strep.       

Is it a cold virus? Strep?

Second, Consider Getting a Strep Test. Strep Testing Will Help Determine Whether The Sore Throat is Viral or Strep

Very occasionally, providers treat strep with an antibiotic according to a patient's presumptive signs and symptoms without testing. These include throat pain, swollen lymph nodes, white patches on tonsils, fever, and absence of a cough. I would add to that absence of a runny nose and known close exposure to strep.

The only way to know for sure if you have strep is to get a strep test. Anyone with one of these would likely remember what it was like. The clinician will touch your tonsils and the back of your throat with a swab. It is unpleasant because it makes most people gag and sputter, but it is an excellent test because it is accurate 95% of the time. Most kids are terrorized by the strep test and will even go to the extreme to tell you that their throat is better to avoid it. Running the test takes about ten minutes.

If it is negative and your practitioner thinks you still might have strep, a swab is sent to a lab to be cultured-grown out on a petri dish to see if it is strep. This test is more expensive and takes about three days to get a result. Usually, when you have a negative rapid strep test in the office, the culture also returns negative.

Strep tests are sold on Amazon and eBay, but I would be cautious about their quality: They are not recommended.

How Much Does a Strep Test Cost?

The rapid strep test is not very expensive - maybe around $12.00, BUT you have to pay for an exam TOO if you have something else going on, to pay the staff and ensure that admin gets a little chunk of change too. If you have insurance, the cost is $300+; if you don't have insurance, the price of a visit is usually around $100 out of pocket at one of those small clinics like Walgreens or CVS clinics. If your rapid strep is negative and you are not terribly ill, I would forego the culture ($$). Those 5-minute tests are excellent (95% accurate). 

If you ONLY have a sore throat for a day, in most cases, the best thing to do is to wait a day or two before you get tested. It's usually something else (see symptoms of strep below). REMEMBER: ONLY 10% OF ADULTS TESTED FOR STREP ARE POSITIVE.

Strep comes in all shapes and sizes: Some people get incredibly sick, and others get very few symptoms. Classic strep is TYPICALLY manifested by a sore throat, fever, body aches, enlarged lymph nodes, a headache, usually NO RUNNY NOSE, and NO SIGNIFICANT COUGH. Adults typically get pretty sick with strep, sometimes feeling like they have the flu. Strep is NOT: " I have no symptoms, but my kid has strep, and I think I might have it too." Sound familiar?

While this site is not for or about kids, I want to give a word of warning about children: small kids with strep may or may not complain of a sore throat—they are weird. They may vomit and go on their merry way; they may have a “ tummy ache,” headache, and fever. They often have dark circles under their eyes, and the energy is just not there. EVERY kid is different. 

When Your Throat Problem Is Diagnosed as Strep Throat, You Will Be Given an Antibiotic

If you have known exposure to strep (for example, one of your kids), it is best to wait and "isolate" until you develop real symptoms: It takes at least a couple of days for it to show up, you may get tested too early, and you may initially test negative.

If you highly suspect that you have strep ("I have these symptoms of strep"), you may want to get tested by a healthcare provider. If you test positive for strep, your provider will treat you with antibiotics (there is no other known treatment for strep besides either time or antibiotics). Antibiotics may shorten the course of your illness by a couple of days and make you noncontagious after 24 hours. If you have strep, keep your distance from others. If you want to wait it out, strep is usually self-limiting, but occasionally can leave other serious diseases behind, like rheumatic fever, kidney problems, and scarlet fever.   

If symptoms are VERY BAD (difficulty swallowing, drooling, "kissing" (touching) tonsils, a rash, and joint pain over time along with a sore throat and do not respond to your treatment, it is time to see a healthcare provider. 

Typically, without an antibiotic for strep, a person's symptoms should go away within three to seven days, but they can be contagious for two to three weeks, and secondary kidney or heart issues can arise. With an antibiotic, symptoms usually go away fast, and a person is infectious for 24 to 48 hours after starting medicine.

Yes, it CAN—and often does—go away on its own. Some people never even know they have had it. Unfortunately, some people freak out when they hear the word "strep." They run to the nearest clinic as quickly as possible for a strep test. Their concern? Lost days at work or school, and the fact that strep is highly contagious, it can go through large families like wildfire. It can also morph into something more serious (although it rarely does), like rheumatic fever or scarlet fever.  Other possible complications? Pneumonia, peritonsillar abscess, glomerulonephritis (even in those treated for strep), and a host of other unusual and remote illnesses. Back in the day, these illnesses were far more common and much more severe than they are today, but still worthy of some concern. One of the most interesting is a recent illness called PANDAS: A person suddenly develops OCD tendencies or a tic after having had strep. The latter is rare in adults.

That said, unless you have had direct contact with someone who has strep and you have symptoms, it will likely be a virus or the onset of a cold. If you get a strep test, you may have peace of mind that it is not strep, but you wasted all that money and time and have been subjected to the discomfort and gag of a strep test. Unless you are pretty ill or immunocompromised, wait a day or two after symptoms start. Avoid close contact with others. Both you and a practitioner (if you end up going to one) will find it easier to diagnose your case.

If you want to know more about a sore throat: Is it strep or a virus, please visit these other posts:

When a sore throat is not due to Strep or a Cold Virus, What Else Can It Be? (with photos)

Tips On How to Care for Your Sore Throat: OTC, Alternative and Herbal Remedies and Prescription Medicines