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.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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3 thoughts on “An Alternate Explanation For Strep Throat & Rheumatic Fever

  1. interesting observation. if it’s just a consequence of swollen tonsils, then you might expect to see a similar syndrome with viral pharyngitis as well, but I’m not aware of that. but it might be that you need sleep apnea from tonsillar hypertrophy in addition to the strep infection in order to develop RF.

  2. Dr. Park,

    Thank you for presenting the blogger’s ideas and discussing them.

    If 1940’s and 1950’s studies show a 50% reduction (from 2% to 1%) in cases of Rheumatic Fever, and the current incidence is 1:1,000,000, then one could conclude that the therapy is incredibly effective, inexpensive, and therefore worth risking the other risk factors.

    Do you have any morbidity/mortality statistics for the allergic, anaphylactic, skin rash, and diarrhea side effects that have been mentioned in your discussion?

    Thank you.