A five-year-old previously healthy girl presented to the emergency department with a six day history of throat and fever. She was seen by a family physician two days into the illness, and was found to have exudative pharyngitis. She was empirically started on amoxicillin. A throat swab was performed at the visit and was positive for group a streptococcus. Despite antibiotic treatment, she had increasing hoarseness, dysphagia, and an increasing fever trend. She denied any neck pain, shortness of breath or abdominal pain. On examination the patient did not appear toxic or in distress, although she was mouth breathing and spoke with a muffled voice. Her temperature was 39.2 c, heart rate was 130 beats/min, blood pressure was 109/67 mmHg, respiratory rate was 30 breaths/min and oxygen saturation was 98% in room air. Her tonsils were symmetrically enlarged with exudate. The uvula was not deviated.She was not drooling and her neck was supple. She had anterior and posterior cervical lymphadenopathy, The abdomen was nontender, and there was no hepatic or splenic enlargement. There was no rash.