September 28, 2009
What A Strange Place For Strep
Billy was an impish five-year-old boy who looked like he could be a poster child for a Norman Rockwell painting. He had an unkempt crop of reddish hair, freckles and a swagger that made you think he was well beyond his age. But when I walked in the examination room he was quietly sitting next to his mom. Clearly something wasn’t right. He was usually outgoing and would give me a high five. But not this time.
Looking at the chart the main complaint listed was “rash”. When asked what was going on mom said that Billy had a really bad rash on his bottom that had been bothering for a couple of weeks. As she spoke, he put his head down and was obviously embarrassed. “His father and I have told him he has to wipe his bottom well. But he is always in such a hurry,” she went on. “Now he has this terrible rash and we have tried everything to clear it up.”
Mom wasn’t sure when it had started. About a week ago, while doing the laundry, she noticed there was some staining in his underwear. That’s when they lectured him about proper hygiene. But it continued and she then noticed there were occasional streaks of blood. She had her husband check Billy’s bottom. Sure enough there was a bright red rash around the anal opening. She had him soak in a tub and applied Desitin, as if it was a diaper rash. This did nothing.
She tried using a fungal cream obtained from the pharmacist, thinking it might be a yeast infection. Again, there was no response. What prompted her visit today was the fact that she actually helped him wipe after a bowel movement and there was bright red blood on the toilet paper. I could tell that Billy was mortified at this discussion. He was embarrassed to no end. To change the subject, I asked him how his T-ball team was doing. He looked at me and in a sad voice said, “I really do wipe well, just like I am told to do!”
Had he had any fever or other symptoms? They both said no. There were no other ill contacts at home. His temperature in my office was normal and he had a completely normal exam…except in the anal area. There was a bright red rash, almost a perfect ring around the peri-anal area that extended about 1½ inches around the anus. It was well demarcated and intensely red. It looked as if it was very painful.
I said, “Billy, I think I have a diagnosis for you. We should know in less than 10 minutes.” I had my nurse come in and do a swab of the area to run a rapid strep test. Sure enough, in a few minutes the results were a strong positive. He had peri-anal strep!
Billy and his mom were cautiously surprised. She asked, “Strep? Why there and how did it get there? Shouldn’t he have a fever?” she asked in rapid fire. Billy just looked relieved to know that it was not something he had done or had not done.
Peri-anal strep is a common skin infection that affects children from six months of age to around ten years of age. It was first described in 1966. It is bacteria that causes the classic “strep throat”. Unlike strep throat, this is not a systemic infection. So you do not see fever, swollen glands or are not ill with it. Rather, it is a superficial skin infection without generalized symptoms. If untreated it can last for weeks and even months.
Over 90% of children with peri-anal strep have the intense red rash around the anus that is well demarcated. It is easily misdiagnosed as a ”diaper-type” rash or a yeast infection. Usual treatments for these are useless. Around 75% of these patients will complain of rectal itching, and about half will complain of discomfort. About a third will experience some blood-streaked stools or blood staining of the toilet paper.
Initially it was thought that the strep passed through the gastro-intestinal tract and colonized the peri-anal area during a strep throat infection. This has been shown to NOT be the case. The acids in the stomach would certainly kill the strep bacterium before they reached the intestine. It was shown that only 6% of patients with strep throat have strep in the peri-anal region.
It is more likely that a person with peri-anal strep has inadvertently inoculated the area by touching themselves with contaminated fingers. They probably picked up the strep bacteria from another child who had strep or impetigo. Although this is a superficial skin infection with no systemic involvement, it MUST be treated with antibiotics just like one would treat strep throat. This is to prevent the post-strep complications from occurring such as rheumatic fever, rheumatic heart disease and post-strep glomerulonephritis.
I wrote Billy a prescription for an antibiotic and told him that he would be like brand new in a few days. His mom was happy and he was thrilled. As he walked out he said, “Gee, thanks doc,” and proceeded to give me a super hard high-five. That was the Billy that I knew!