Perianal strep – “strep butt” in an adult

 One of the joys of being a physician is treating family members over the phone.  For the past two weeks, I've done my best to help a family member 3000 miles away with rectal itching.   Amid phone calls about "my hiney hole" … we've run through the list of disorders that could be causing the problem.  The note home from the kids' school about pinworm turned out to be a red herring .. as the course of mebendazole didn't help much, and the stool was negative for parasites.  

And so this went on-and-on.  Her physician (an internist) diagnosed hemorrhoids .. but treatment didn't help at all.  ?A fungal infection?  The physician tried antifungals. No change … it even seemed a bit worse.

Weeks pass .. and still no resolution.  I start to try to learn about the physical signs.  The husband gets involved.. he reports a bright red area around the anus. 

She's got two kids – 6 and 4.  Hmmm … the only thing I can think of that hasn't been considered is GABHS.  I haven't seen "strep butt" in an adult .. but kids do get it .. and I see a few cases of it every year.  Could this 36 year old mother-of-two-likely-strep-vectors get it?  I don't see why not.  I suggest this .. and suggest that she get a strep culture (or even a rapid test) from her physician.

End of long story:  after working (very) hard to convince her physician (who had never heard of perianal strep) that this was a reasonable diagnostic test .. my relative received a phone call today from her very surprised physician – "very heavy GABHS." 

While reasonably common in children, now we all know GABHS can be seen in adults too.