8 y/o with sore throat, fever, and loss of appetite
Patient will present as → a 7-year-old boy is brought to his pediatrician for evaluation of a sore throat. The sore throat began 4 days ago and has progressively worsened. Associated symptoms include subjective fever, pain with swallowing, and fatigue. The patient denies cough or rhinorrhea. Vital signs are as follows: T 101.4 F, HR 88, BP 115/67, RR 14, and SpO2 99%. Physical examination is significant for purulent tonsillar exudate; no cervical lymphadenopathy is noted.
I. Bacterial pharyngitis:
- Group A Streptococcal pharyngitis: 5-15% of pharyngitis cases, S. pyogenes.
- Centor Criteria: GABHS-suggestive manifestations include fever (> 38°C or 100.4°F), tender anterior cervical adenopathy, lack of cough, and pharyngotonsillar exudate.
- Rapid streptococci screening for GABHS has 90% to 99% sensitivity. If negative and group A streptococci is still suspected, throat culture is the gold standard
- Rheumatic fever and post-strep glomerulonephritis
- Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis.
II. Viral Pharyngitis
- Less likely exudative: CMV, EBV (mononucleosis), adenovirus (most common), influenza, herpes simplex
- Infectious mononucleosis: Caused by Epstein Barr virus, characterized by malaise, fever, severe sore throat, splenomegaly
- Rash with penicillins
- Diagnosed by atypical lymphocytes, heterophile agglutination test (monospot)
- Splenic rupture possible with trauma/contact sports
III. Fungal Pharyngitis
- Common in patients using inhaled steroids – counsel patients to rinse mouth after use of inhaled steroids.
Centor criteria: 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy
- Not suggestive of strep - coryza, hoarseness, and cough
- If 3 out of 4 Centor criteria are met get a rapid streptococcal test (sensitivity > 90%)
- If negative → throat culture is the gold standard
Group A Streptococcal pharyngitis: Intramuscular (IM) penicillin can be used if patient compliance is in doubt. Otherwise, oral penicillin or cefuroxime can be used
- Erythromycin or another macrolide can be substituted in cases of penicillin allergy
- Inadequate treatment can lead to complications such as scarlet fever, glomerulonephritis, and abscess formation
Infectious mononucleosis (Epstein Barr virus): Symptomatic and avoid contact sports (splenic rupture), steroids if respiratory distress. Ampicillin and amoxicillin cause rash
- For athletes planning to resume non-contact sports, training can be gradually restarted starting three weeks from symptom onset
- For strenuous contact sports (including football, gymnastics, rugby, hockey, lacrosse, wrestling, diving, and basketball) or activities associated with increased intraabdominal pressure (such as weightlifting) ⇒ four weeks after illness onset
Fungal: clotrimazole, miconazole, or nystatin
Gonorrhea pharyngitis: Same principles for the approach to therapy of uncomplicated urogenital gonococcal infections, with a preferred regimen of intramuscular ceftriaxone (250 mg) and azithromycin as a second agent
Antibiotics are not indicated in the treatment infectious mononucleosis, or Epstein-Barr virus infections.
See A for explanation.
Acyclovir is not approved for use in treatment of EBV, although it is active against the EBV in vitro and in vivo. It may be used in certain patients with AIDS, but has not been shown to affect the outcome of EBV in these patients.
Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.
Group C Streptococcus
Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates
Neisseria gonorrhea of the pharynx may be asymptomatic