PHARYNGITIS   9A

A 19-year-old woman presents to her primary care clinic complaining of a sore throat for 2 days. She also reports a fever that reached 38.4°C yesterday. She denies cough. A friend at her place of employment has also had similar symptoms. On physical examination, her neck reveals tender anterior cervical lymphadenopathy, and her tonsils are inflamed and exudative.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Young age; sick contact; sore throat; fever; lack of cough; cervical adenopathy; exudative tonsils

How to think through: Assessment of acute pharyngitis in adults requires the clinician to separate viral pharyngitis from probable group A β-hemolytic streptococcus infection while remaining vigilant for more serious causes of sore throat. Why is it important to identify and treat group A β-hemolytic streptococcal pharyngitis? (Risk of subsequent rheumatic fever and glomerulonephritis.) How many Centor criteria are present in this patient? (Four of four diagnostic criteria: fever, absence of cough, tender cervical lymphadenopathy, tonsillar exudate.) If a rapid strep test result were negative in this case, what would be the appropriate management strategy? (Antibiotic therapy in a patient with four of four the Centor criteria is reasonable regardless of the rapid test result.) What other important infectious diseases present with pharyngitis in young adults and must be considered? (Lemierre’s syndrome [Fusobacterium necrophorum], acute HIV infection, gonococcal pharyngitis, infectious mononucleosis [Epstein-Barr virus or EBV], and cytomegalovirus infection.) If infectious mononucleosis was a consideration, what antibiotic should be avoided because of the high frequency of associated rash? (Ampicillin.) If the patient provides a history of a recent high-risk sexual encounter, should she receive an HIV antibody test now? (No. Detectable antibodies take between 3 weeks and 2 months to form in the majority of infected patients. An HIV viral load nucleic acid test would be more appropriate.)

PHARYNGITIS   9B

What are essentials of diagnosis and general considerations regarding pharyngitis?

Essentials of Diagnosis

Sore throat, fever, anterior cervical adenopathy, and tonsillar exudate suggest group A β-hemolytic streptococcus infection.

General Considerations

The main concern is to determine whether the cause is group A β-hemolytic streptococcal infection because of the complications of rheumatic fever and glomerulonephritis.

About one-third of patients with infectious mononucleosis have secondary streptococcal tonsillitis requiring treatment.

Ampicillin should routinely be avoided if mononucleosis is suspected because it induces a rash.

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