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Emergency And Acute Medicine – Pharyngitis
Pharyngitis is inflammation or infection of the pharynx and is the third most common reason for physician visits, with approximately 30 million cases diagnosed annually. Although viral infections are the most common cause, Group A β-hemolytic Streptococcus (GAS), caused by Streptococcus pyogenes, remains the most clinically significant bacterial etiology because of potential complications. GAS is uncommon in children younger than 3 years, accounts for 20–30% of childhood pharyngitis, and 5–15% of adult cases. Incidence peaks between January and May and at the beginning of the school year, with highest rates in children aged 5–7 and 12–13 years.
Viral causes include rhinovirus, coronavirus, adenovirus, herpes simplex virus, parainfluenza, influenza, coxsackievirus, Epstein–Barr virus, and acute HIV infection. Bacterial causes include GAS, Fusobacterium necrophorum (notably associated with Lemierre disease), group C and G streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Arcanobacterium haemolyticum, Mycoplasma pneumoniae, Chlamydia pneumoniae, and less commonly syphilis or tuberculosis. Noninfectious causes include Candida infection, chemical irritation, foreign bodies, inhalants, postnasal drip, malignancy, and GERD.
History helps differentiate viral from bacterial etiologies. Viral pharyngitis is often preceded by cough, rhinorrhea, and coryza. Acute HIV should be considered in at-risk patients with persistent pharyngitis. GAS typically presents with sudden-onset sore throat, fever, odynophagia, headache, abdominal pain, nausea, and vomiting. Cough, hoarseness, coryza, and diarrhea are less typical of GAS and suggest viral infection.
Physical examination must first assess for high-risk features such as stridor, respiratory distress, drooling, dysphonia, marked neck swelling, or neurologic dysfunction. Viral findings commonly include cough, rhinorrhea, and pharyngeal erythema. GAS is characterized by tonsillopharyngeal erythema with or without exudates, soft palate petechiae, a beefy red swollen uvula, tender anterior cervical lymphadenopathy, and sometimes a scarlatiniform rash. Conjunctivitis and ulcerative lesions suggest viral infection. Infectious mononucleosis may mimic GAS, presenting with exudative pharyngitis, fever, lymphadenopathy, rash, and possibly hepatosplenomegaly or jaundice. Diphtheria should be suspected in nonimmunized patients with a gray pharyngeal membrane and potential myocarditis or neuropathy. Gonococcal pharyngitis may be asymptomatic and requires consideration of sexual history and child protection concerns when appropriate.
The modified Centor (McIsaac) criteria guide testing decisions for GAS. Criteria include absence of cough, tonsillar exudates or swelling, tender anterior cervical nodes, fever >38°C, and age adjustment. Patients with low scores (<1) should not be tested or treated. those with a score of 3 undergo rapid antigen detection testing (radt), and some clinicians treat empirically when scores exceed 4. overuse empiric antibiotics without contributes to inappropriate prescribing.< />pan>
Throat culture remains the gold standard but requires 24–48 hours. RADT provides results within 30 minutes, with high specificity and good sensitivity. In children and adolescents, negative RADT results should be confirmed with culture. Proper swabbing technique is essential. Monospot testing supports diagnosis of infectious mononucleosis, though sensitivity varies by age. CBC may reveal lymphocytosis with atypical lymphocytes in mononucleosis. Imaging such as lateral neck radiographs or contrast-enhanced CT is reserved for suspected complications like epiglottitis, peritonsillar abscess, or retropharyngeal abscess.
Treatment begins with airway assessment and supportive care, including hydration and analgesia with acetaminophen or ibuprofen. GAS infection is often self-limited, but antibiotics reduce symptom duration by 1–2 days and prevent acute rheumatic fever and suppurative complications. Penicillin V or benzathine penicillin G is first-line therapy. Amoxicillin is commonly used due to palatability. Macrolides or cephalosporins are alternatives for penicillin-allergic patients. Corticosteroids may modestly improve symptom resolution when used with antibiotics but should be avoided in certain populations such as diabetics or immunocompromised patients.
Potential complications of streptococcal infection include suppurative conditions such as peritonsillar abscess, retropharyngeal abscess, otitis media, mastoiditis, and Lemierre disease. Nonsuppurative complications include acute rheumatic fever, poststreptococcal glomerulonephritis, Sydenham chorea, and reactive arthritis. PANDAS remains controversial. Diphtheria requires urgent antimicrobial therapy and airway management. Gonococcal pharyngitis is treated with ceftriaxone plus coverage for possible Chlamydia coinfection.
Patients require admission if there is airway compromise, severe dehydration, or concern for abuse. Most patients who tolerate oral intake can be discharged with appropriate follow-up. Symptoms should improve within 72 hours of appropriate therapy. Patients with GAS are no longer contagious after 24 hours of antibiotics. Individuals with mononucleosis should avoid contact sports due to splenic rupture risk. Careful use of clinical decision rules, confirmation of negative RADT in children, and vigilance for complications are essential to appropriate management.
Pharyngitis is inflammation or infection of the pharynx and is the third most common reason for physician visits, with approximately 30 million cases diagnosed annually. Although viral infections are the most common cause, Group A β-hemolytic Streptococcus (GAS), caused by Streptococcus pyogenes, remains the most clinically significant bacterial etiology because of potential complications. GAS is uncommon in children younger than 3 years, accounts for 20–30% of childhood pharyngitis, and 5–15% of adult cases. Incidence peaks between January and May and at the beginning of the school year, with highest rates in children aged 5–7 and 12–13 years.
Viral causes include rhinovirus, coronavirus, adenovirus, herpes simplex virus, parainfluenza, influenza, coxsackievirus, Epstein–Barr virus, and acute HIV infection. Bacterial causes include GAS, Fusobacterium necrophorum (notably associated with Lemierre disease), group C and G streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Arcanobacterium haemolyticum, Mycoplasma pneumoniae, Chlamydia pneumoniae, and less commonly syphilis or tuberculosis. Noninfectious causes include Candida infection, chemical irritation, foreign bodies, inhalants, postnasal drip, malignancy, and GERD.
History helps differentiate viral from bacterial etiologies. Viral pharyngitis is often preceded by cough, rhinorrhea, and coryza. Acute HIV should be considered in at-risk patients with persistent pharyngitis. GAS typically presents with sudden-onset sore throat, fever, odynophagia, headache, abdominal pain, nausea, and vomiting. Cough, hoarseness, coryza, and diarrhea are less typical of GAS and suggest viral infection.
Physical examination must first assess for high-risk features such as stridor, respiratory distress, drooling, dysphonia, marked neck swelling, or neurologic dysfunction. Viral findings commonly include cough, rhinorrhea, and pharyngeal erythema. GAS is characterized by tonsillopharyngeal erythema with or without exudates, soft palate petechiae, a beefy red swollen uvula, tender anterior cervical lymphadenopathy, and sometimes a scarlatiniform rash. Conjunctivitis and ulcerative lesions suggest viral infection. Infectious mononucleosis may mimic GAS, presenting with exudative pharyngitis, fever, lymphadenopathy, rash, and possibly hepatosplenomegaly or jaundice. Diphtheria should be suspected in nonimmunized patients with a gray pharyngeal membrane and potential myocarditis or neuropathy. Gonococcal pharyngitis may be asymptomatic and requires consideration of sexual history and child protection concerns when appropriate.
The modified Centor (McIsaac) criteria guide testing decisions for GAS. Criteria include absence of cough, tonsillar exudates or swelling, tender anterior cervical nodes, fever >38°C, and age adjustment. Patients with low scores (<1) should not be tested or treated. those with a score of 3 undergo rapid antigen detection testing (radt), and some clinicians treat empirically when scores exceed 4. overuse empiric antibiotics without contributes to inappropriate prescribing.< />pan>
Throat culture remains the gold standard but requires 24–48 hours. RADT provides results within 30 minutes, with high specificity and good sensitivity. In children and adolescents, negative RADT results should be confirmed with culture. Proper swabbing technique is essential. Monospot testing supports diagnosis of infectious mononucleosis, though sensitivity varies by age. CBC may reveal lymphocytosis with atypical lymphocytes in mononucleosis. Imaging such as lateral neck radiographs or contrast-enhanced CT is reserved for suspected complications like epiglottitis, peritonsillar abscess, or retropharyngeal abscess.
Treatment begins with airway assessment and supportive care, including hydration and analgesia with acetaminophen or ibuprofen. GAS infection is often self-limited, but antibiotics reduce symptom duration by 1–2 days and prevent acute rheumatic fever and suppurative complications. Penicillin V or benzathine penicillin G is first-line therapy. Amoxicillin is commonly used due to palatability. Macrolides or cephalosporins are alternatives for penicillin-allergic patients. Corticosteroids may modestly improve symptom resolution when used with antibiotics but should be avoided in certain populations such as diabetics or immunocompromised patients.
Potential complications of streptococcal infection include suppurative conditions such as peritonsillar abscess, retropharyngeal abscess, otitis media, mastoiditis, and Lemierre disease. Nonsuppurative complications include acute rheumatic fever, poststreptococcal glomerulonephritis, Sydenham chorea, and reactive arthritis. PANDAS remains controversial. Diphtheria requires urgent antimicrobial therapy and airway management. Gonococcal pharyngitis is treated with ceftriaxone plus coverage for possible Chlamydia coinfection.
Patients require admission if there is airway compromise, severe dehydration, or concern for abuse. Most patients who tolerate oral intake can be discharged with appropriate follow-up. Symptoms should improve within 72 hours of appropriate therapy. Patients with GAS are no longer contagious after 24 hours of antibiotics. Individuals with mononucleosis should avoid contact sports due to splenic rupture risk. Careful use of clinical decision rules, confirmation of negative RADT in children, and vigilance for complications are essential to appropriate management.
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