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Shocking Revelations About Strep Throat

This is a bit off the topic of sleep apnea, but definitely relevant for everyone. I just finished reading Dr. David Newman’s book, Hippocrates’ Shadow:What Doctors Don’t Know, Don’t Tell You, and How Truth Can Repair the Patient-Doctor Breach. It was an eye-opening book, confirming my suspicions that many of the routine forms of therapy that we as doctors prescribe are more based on tradition or flawed logic than real science.

One shocking example is our obsession with treating Strep throat with oral antibiotics. The main reason why treatment is recommended is to prevent rheumatic fever. In the 1940s on an army base, there was an epidemic of streptococcal infections and rheumatic fever, which can lead to heart disease. By treating with antibiotics, they were able to lower the incidence of rheumatic fever from 2% to 1%. Calculations showed that they had to treat 50-60 soldiers to prevent one case of rheumatic fever.

Now that rheumatic fever is almost nonexistent, it’s estimated that you need to treat 1 million people with strep throat to prevent one case of rheumatic fever. What most doctors don’t realize is that every time you give antibiotics, you have a 10% chance of developing a rash, 10% chance of having diarrhea, and 10% of of suffering from a yeast infection. That’s potentially 300,000 complications. Furthermore, 0.24% of people will suffer a potentially life-threatening allergic reaction, and of these, about 1 out of every 10 will die (240 people). What’s worse, only about 1/3 of people with rheumatic fever will develop long-term heart disease. So you’ll have to treat 3 million people with antibiotics to prevent one case of heart disease. That means 900,000 people will suffer complications and about 720 people may die. Ten million antibiotics are prescribed in this country every year for throat infections.

Does this mean that we should shop prescribing antibiotics? Absolutely not. In selected situations, it would be inappropriate to withhold antibiotics. But in most cases, antibiotics are prescribed for a sore throat, viral infections, or a slight suspicion of a bacterial infection. In many instances, tonsils can become huge and obstruct your breathing, aggravating sleep apnea temporarily. Sometimes it can even lead to an abscess.

I still remember the one time I had Strep throat when I was a senior in high school. I was spiking fevers, sweating profusely, and was weak, dizzy and lightheaded. I was miserable. Despite this I played my bass clarinet solo in our annual symphonic band concert. After the performance, my father took me to the local ER, where they saw huge, inflamed tonsils. I was tested positive for Strep, and was given a penicillin shot. The next day, I felt 95% better. The point of this story is that we should try to avoid using antibiotics inappropriately, especially when there’s no absolute need.

Here’s a related short discussion on this topic.

An Alternate Explanation For Strep Throat & Rheumatic Fever

KevinMD had a guest blogger who questioned the value of needing to treat one million strep throat infections with antibiotics to save one patient from rheumatic fever and heart disease. Typically, we only need to treat a particular strain of strep called Group A beta-hemolytic Strep (GABHS), which produces a particular type of toxin and antigen. However, non-GABHS is often treated with antibiotics, as well as for a significant number of viral throat infections.

This practice is based on studies in the 1940 and 1950s showing that the rate of rheumatic fever in children can be cut 50% from 2% to 1%. Currently, the rate of rheumatic fever in the US is 1 per 1 million people with strep throat. On the other hand, one million courses of antibiotics can cause 2,400 cases of significant allergic reactions including anaphylactic reactions, 50,000 to 100,000 cases of diarrhea and 100,000 cases of skin rash. Here’s another article that states that strep throat risks are greatly exaggerated.

There’s a lot of merit in what Dr. Lundberg has to say, but when I reviewed the symptoms of rheumatic fever, I was shocked to see how all the symptoms sounded like an acute episode of obstructive sleep apnea. Let me explain:

Rheumatic fever typically occurs in children, and usually presents about 2-3 weeks after a strep infection. Children will naturally have large tonsils. If inflamed for whatever reason (virus, bacteria, allergies, etc.), they’ll get larger by definition. Having large tonsils all of a sudden will close off your throat suddenly, preventing you from breathing properly at night while sleeping. This sudden onset of sleep apnea can cause a number of systemic symptoms which are very similar to the classically described symptoms of rheumatic fever:

• fever
• painful, tender, red and swollen joints
• heart palpitations
• chest pain
• shortness of breath
• skin rashes
• severe fatigue
• skin nodules.

You may be thinking, how do these symptoms relate to sleep apnea?

If you have any type of infection, you’ll also have fever. Also, having sudden breathing pauses will cause vasomotor symptoms which can also produce fever, chills, hot flashes and night sweats (similar to menopause).

There are numerous reports of rheumatoid arthritis resolving completely with sleep apnea treatment. Obstructive sleep apnea, by definition causes systemic inflammation, which can even affect your joints.

Not breathing well at night can stimulate your heart, causing palpitations. This can also cause shortness of breath.

Numerous dermatologic conditions have also been linked to sleep apnea. Many people report that their psoriasis or eczema improves after sleep apnea treatment.

Sleep apnea causes a hyper-coagulable state. This can cause micro-strokes or throw small clots to the most remote parts of the body (skin).

Sudden onset of sleep-breathing problems can initiate an intense autoimmune response, since sudden stress can stimulate your immune system.

Granted, toxins from a strep infections can aggravate many of these problems. However, heart valve biopsies in patients with rheumatic fever only sometimes show inflammation and scarring, similar to what we may see with autoimmune conditions. Bacteria or toxins are usually not found.

I have to say that there are certain situations where strep must be treated, but the vast majority of people who have strep don’t actually have a true infection, and even if they do test positive on a culture, they could be one of the 15% of normal carriers, who just happened to have a viral infection, or reflux. The words strep throat is definitely over-used these days—oftentimes people with any degree of throat pain will say they have strep throat.

Furthermore, since most adults will have much smaller tonsils, your risk of having heart complications will probably be much lower compared to children’s risks.

To date, I’m not aware of any solid prospective evidence-based study what supports our current guidelines for routine treatment for strep, especially for adults. I suspect a new study in the future will completely reverse the current management of strep. Unfortunately, even if such a study does surface, it’ll be very difficult for physicians to change their ways.

How often do you test positive for strep? If so, how often are you prescribed antibiotics even if it comes back negative?

 

Click here for a follow-up discussion about the dangers of Strep throat over-treatment.

Is That Scratchy Throat Really A Cold? The Case Against Strep Throat (Part 2)

In my last post I described a typical person that sees me for a few day history of throat pain. She has cold-like symptoms, but her exam is essentially normal. Her voice box does show mild swelling and inflammation, consistent with laryngopharyngeal reflux disease. 

Upon further questioning, she remembers that she did have a late dinner with alcohol the night before she woke up with her throat pain. This confirms her laryngopharyngeal reflux disease diagnosis. But why does eating late cause throat pain the next morning, accompanied by cold symptoms? As I describe with my sleep-breathing paradigm, most modern humans stop breathing to various degrees at night while sleeping. If you're susceptible to this condition (due to having smaller jaw structures), having any additional stomach juices when you go to sleep will allow it to be suctioned up into the throat every time you stop breathing. 

Not only does this cause throat pain and additional swelling and inflammation, it also aggravates more frequent obstructions and arousals, which suctions up more stomach juices.

Well, that explains throat pain, but why would you have fever, chills, and sweats? Isn't this classic for cold symptoms?

Whether inflammation begins with a cold or from reflux, they both cause additional swelling in the throat, aggravating more tongue collapse. When the tongue falls back more and more frequently, this process upsets the balance with your involuntary nervous system. This causes vasomotor symptoms such as fever, night sweats, flashes, and chills. So what may seem like a cold can actually be a nervous system overreaction, with no sign of infection whatsoever.

In this example patients, I just had her stop eating close to bedtime (along with alcohol), as well as to optimize her nasal breathing, by using nasal saline and nasal dilator strips. Usually, most of these problems  go away within a few days.

What can you do if it doesn't go away? Find out my answer in a future blog.

Is That Scratchy Throat Really A Cold? The Case Against Strep Throat (Part 1)

Here's a typical patient that I see 2-3 time every day in my practice: A young woman comes in complaining of waking up Sunday morning with a sore and scratchy throat. She thinks she may have caught her husband's cold, since she is also experiencing some sweats, low-grade fever and unrefreshing sleep. I ask repeatedly if she did something out of the ordinary a few days prior to the onset of her symptoms, and she says no. She denies any traveling, flying, eating or drinking late. She normally sleeps on her stomach, and her father snores like a train. She's worried that she has Strep throat. 

Her general exam, as expected, is normal. No throat inflammation, redness or swollen glands. Looking via a flexible endoscope, the back of her voice box is slightly inflamed and swollen, but there's absolutely no evidence of infection? What would you do?

Q: How do I know if I have Strep throat?

A: The only official way is to undergo a throat culture (which takes 2-3 days), or undergo a rapid “Strep” test in the office (but only 80-90% accurate). The only strain of bacteria that’s tested for is GABHS, or group A beta hemolytic streptococcus. This particular strain of bacteria can produce toxins that can potentially injure the heart or the kidneys. There are many other types of “Strep” that can also cause throat infections, but are harmless to vital organs. In most cases, GABHS presents with high fever (102 to 103˚ F), pus on the tonsils or throat, and very swollen, inflamed neck glands. Severe throat pain by itself is not a reason to treat with oral antibiotics.

 

 

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