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Practice Practice Pointer

Group A beta-haemolytic streptococcal infection in children

BMJ 2024; 385 doi: (Published 02 April 2024) Cite this as: BMJ 2024;385:e077561
  1. Marina Morgan, consultant microbiologist1,
  2. Stefanie Shaw, general practitioner2 3,
  3. Tamer Ali, consultant plastic and reconstructive surgeon1,
  4. Yvonne Hodges, general practitioner3 4
  1. 1Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
  2. 2St Thomas Medical Group, Exeter
  3. 3Patient author (carer of a child with group A beta-haemolytic streptococcal infection)
  4. 4Axminster Medical Practice, Axminster
  1. Correspondence to M Morgan marinamorgan{at}

What you need to know

  • Group A beta-haemolytic streptococcal (GAS) infections, including pharyngitis and more complex invasive infections, can be difficult to diagnose clinically

  • In December 2022, rates of invasive infection in the UK increased substantially, with a high number of children presenting with empyema

  • Suspect invasive infection, including necrotising fasciitis and streptococcal toxic shock-like syndrome, in any child who is unwell and presents with severe or disproportionate pain in the setting of recent varicella zoster virus or GAS infection

A 5 year old girl presents to her GP with a three day history of fever up to 39°C, sore throat, myalgia, headache, lack of appetite, and lethargy. When afebrile, her observations are within normal limits. On examination, both tonsils are red, inflamed, and have exudate. The child’s parents work in healthcare, and have a recent history of sore throats that were not medically treated. A clinical diagnosis of suspected streptococcal pharyngitis is made and a 10 day course of penicillin V prescribed. The child re-presents 48 hours later with persistent fevers and new onset vomiting and diarrhoea. She has managed to take only half of her prescribed doses of penicillin V. On examination, she is tachycardic and has cool peripheries. She has developed a sandpaper rash on her trunk, and her tonsils remain inflamed, with exudate. Her forearm is moderately swollen, and she screams when it is palpated lightly.

Group A beta-haemolytic streptococci (GAS) are Gram positive bacteria resembling chains (“streptos”) of berries (“kokkus”) that colonise mucus membranes and damaged skin. They are spread by skin contact and respiratory droplets. People of all ages are susceptible, but especially children, pregnant women, and older adults. Invasive GAS (iGAS) refers to when GAS moves from “colonising” skin or mucosal surfaces, reaching normally sterile sites such as blood, cerebrospinal, synovial, or pleural fluids, or deep tissues.

Manifestations …

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