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Sunday, September 14, 2008

Despite the antibiotics: Strep throat and a missed diagnosis

"I – can't - breathe," the boy gasped. There was panic in his voice and face. He moved restlessly in his hospital bed, tugging at the clear plastic mask that covered his mouth and nose. It was unusual for a 17-year old boy to be in the pediatric intensive care unit.

Earlier that morning, the boy had a fever, but otherwise looked well. Now his condition had deteriorated: he was breathing at three times the normal rate, he had bone-wrenching chills, and was spiking fevers up to 105 degrees. There was very little oxygen in his blood.

Six days earlier, the boy had awakened with a fever and sore throat. His family doctor had diagnosed strep throat the next day, and had begun azythromycin, an antibiotic that is usually effective against strep. The diagnosis was obvious, and no strep test was done.

Despite the antibiotics, the boy continued to spike fevers up to 102 degrees, and pain and swelling had migrated from his throat to the right side of his neck. The boy's parents took him to the hospital because something scared them; his responses were slow and strangely deliberate.

During three days in the hospital, doctors and other clinicians performed a variety of consultations and diagnostic tests. A blood culture developed a strange bacteria – Fusobacterium necrophorum – which enabled the diagnosis of Lemierre's disease, which is treatable through antibiotics. In the meantime, however, the boy’s condition had worsened, and he had to be put on a ventilator to get him enough oxygen.

His lungs never recovered, and he died in the intensive care unit three weeks later.

The family doctor, heartbroken over his missed diagnosis, now says that every patient in his practice with suspected strep will have a throat culture.

Advice to parents with children who may have strep: Ask to have a strep test or throat culture to confirm the diagnosis.

Thanks to Dr. Lisa Sanders for the source story in today's New York Times Magazine.

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