• Nicole L Nadeau, Andrew M Fine, and Amir Kimia.
• Division of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, United States of America. Electronic address: nnadeau@partners.org.
• Am J Emerg Med. 2021 Jul 1; 45: 196-201.

BackgroundPalatal petechiae are predictive of Group A streptococcal (GAS) pharyngitis. We sought to (a) quantify the value of considering petechiae in addition to exudate, and (b) assess provider incorporation of petechiae's predictive nature for GAS into clinical decision making.MethodsWe conducted a cross-sectional study of patients 3-21 years with sore throat and GAS testing performed in a pediatric emergency department (ED) in 2016. Patients were excluded if immunosuppressed, nonverbal, medically complex, had chronic tonsillitis, or received antibiotics in the preceding week. As a proxy of provider incorporation of petechiae into clinical decision making we assessed how often petechiae were documented, compared with exudate. We performed univariate analysis using χ2 analysis for categorical data and Mann-Whitney U test for continuous data.Results1574 patients met inclusion criteria. Median age 8 years [IQR 5, 13]; 54% female. 372 patients (24%) were GAS positive. Both palatal petechiae and tonsillar exudates were predictive of GAS [OR 8.5 (95% CI 5.2-13.9), and 1.9 (95% CI 1.4-2.6) respectively]. Examining petechiae or exudate vs. exudate alone increases OR from 1.9 to 2.9 (95% CI 2.2-3.8). Sensitivity improves (23% to 34%) with minimal change to specificity (87% to 85%). Among those with a normal or erythematous throat exam, petechiae were mentioned as a pertinent negative in 28%; absence of tonsillar exudate was mentioned in 78% (p = .02).ConclusionsPalatal petechiae are highly associated with GAS, yet rarely addressed in documentation. Incorporating palatal petechiae into common scoring systems could improve prediction and disseminate this knowledge into practice.Copyright © 2020 Elsevier Inc. All rights reserved.

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