Sore Throat

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CHAPTER 24 Sore Throat

Magdy W. Attia, MD, Yamini Durani, MD

1 How do you define acute pharyngitis, tonsillitis, and pharyngotonsillitis?

Acute pharyngitis is an infection of the tonsils or the pharynx. Pharyngitis, tonsillitis, and pharyngotonsillitis are interchangeable terms often used to describe the clinical diagnosis of sore throat regardless of the etiology.

2 What is the incidence of pharyngitis in children?

The exact incidence of pharyngitis is not known. It is, however, the second most common diagnosis in children 1–15 years of age in the ambulatory setting.

3 What is the most common etiology for pharyngitis?

Viral agents account for most cases of pharyngitis seen in children as well as adults (70–80%). These include:

image Rhinoviruses

image Epstein-Barr virus

image Parainfluenza viruses

image Influenza A and B

image HIV

image Adenovirus

image Herpes simplex virus types 1 and 2

image Enteroviruses

image Cytomegalovirus

4 How can I distinguish throat infections caused by these viruses?

The signs and symptoms often overlap between different causes of throat infection. Some helpful diagnostic clues are as follows:

image When pharyngitis is associated with conjunctivitis, the diagnosis of pharyngoconjunctival fever secondary to adenovirus is highly likely.

image The presence of ulcerative lesions on an erythematous base on the posterior palate is associated with coxsackie A virus, a condition known as herpangina. Another variant of coxsackie pharyngitis is hand, foot, and mouth disease. Small vesiculopustular lesions or shallow ulcers are seen on the soft palate, palms, and soles.

image The association of significant cervical or generalized adenopathy and hepatosplenomegaly is highly suspicious for infectious mononucleosis due to Epstein-Barr virus or, less commonly, cytomegalovirus.

5 Which bacterial pharyngitis is the most common?

Streptococcus pyogenes, also known as group A β-hemolytic streptococcus (GABHS), is the most common bacterium causing pharyngitis in children. It is implicated in as many as 20–30% of all cases of pharyngitis in children. Other bacterial causes of sore throats (group C β-hemolytic streptococci, group G β-hemolytic streptococci, Mycoplasma pneumoniae, Neisseria gonorrhoeae) are much less common and almost irrelevant to everyday practice.

6 Why is it important for clinicians to diagnose and treat GABHS pharyngitis?

Antibiotic treatment of GABHS pharyngitis prevents rheumatic fever and suppurative complications. In addition, early treatment of GABHS pharyngitis shortens the course of the disease and reduces transmission to contacts.

7 Can rheumatic fever occur after a skin GABHS infection or after non-GABHS pharyngitis?

No. It is only known to occur after GABHS pharyngitis.

8 List the suppurative complications of GABHS.

These include peritonsillar cellulitis or abscess (quinsy), retropharyngeal abscess, cervical adenitis, otitis media, and sinusitis.

9 What are other important complications of GABHS infections? Does treatment of GABHS prevent these complications?

Poststreptococcal glomerulonephritis (GN) is one of the complications of GABHS. Treating GABHS infection does not prevent poststreptococcal GN. Poststreptococcal GN can occur following non-GABHS, particularly groups C and D. Toxin-mediated diseases, such as scarlet fever and toxic shock syndrome, are also important complications of GABHS infection.

KEY POINTS: TREATMENT OF STREP THROAT

1 Shortens the course of the disease

2 Prevents suppurative complications

3 Prevents rheumatic fever

4 Reduces transmission to contacts

5 Does not prevent poststreptococcal glomerulonephritis

10 What are the clinical features of GABHS pharyngitis?

image Sudden onset of fever and sore throat in a school-aged child. Fever is often low grade or absent.

image Scarlatiniform rash—an erythematous, fine, sandpaper-like exanthem that generally appears in axillary and inguinal folds before it is generalized. It is pathognomonic for GABHS infection.

image Headache, vague abdominal pain, nausea, vomiting, and halitosis may be present.

image The pharynx is erythematous, and the tonsils are enlarged. Tonsillar exudate, palatine petechiae, and nasal excoriation may be noticed. Nasal excoriation is rare but more common in the younger child.

image Significant submandibular lymphadenopathy is usually present.

image Absence of cough or coryza is characteristic.

Attia MW, Zaoutis, T, Klein JD, Meier FA: Performance of a predictive model for streptococcal pharyngitis in children. Arch Pediatr Adolesc Med 155:687–691, 2001.

11 True or False: GABHS pharyngitis is usually obvious and easy to diagnose clinically.

False. Initially, signs and symptoms are often absent because of the child’s early presentation to clinicians. GABHS and viral pharyngitis have many overlapping clinical features and are often difficult to distinguish from one another.

12 Are some of the signs and symptoms more reliable than others in diagnosing strep throat?

Yes. Scarlatiniform rash, large and tender submandibular lymph nodes, and the absence of coryza are more reliable than fever and tonsillar exudates. The latter two features are more common and reliable in adults.

Del Mar CB: A clinical prediction model did well in diagnosing pediatric group A beta-hemolytic streptococcal pharyngitis. ACP J Club 136:37, 2002.

13 What laboratory tests are available to diagnose GABHS infections? What are their advantages and disadvantages?

Throat culture is considered the gold standard for diagnosing GABHS pharyngitis, though it has limitations. Throat culture has a relatively high incidence of false-negative results (10–20%). Also, a positive throat culture for GABHS without serologic evidence does not distinguish between carrier state and an acute infection. Finally, cultures may take 24–48 hours of incubation to detect GABHS which may delay diagnosis and care.

Alternative tests include serologic testing (ASO, anti-Dnase) and rapid antigen tests. Serologic testing is impractical in the acute evaluation of suspected GABHS pharyngitis. Rapid antigen tests by a reference laboratory method are highly specific, but the sensitivity varies (60–90%) depending on the practice. Hence, the American Academy of Pediatrics recommends use of rapid antigen tests only in conjunction with throat cultures.

Currently under investigation is a new rapid real-time polymerase chain reaction test to detect GABHS pharyngitis with potentially high sensitivity and specificity.

14 What is the carriage rate of GABHS in healthy children?

10–20% of healthy children have a positive throat culture for GABHS while they are asymptomatic (i.e., carriers).

15 What is the antibiotic of choice for treating GABHS sore throat?

Penicillin is the mainstay of treatment for GABHS pharyngitis. Resistance to penicillin has never been documented. It is least expensive and has a proven efficacy. Oral penicillin V or a penicillin derivative such as amoxicillin is most often used (because liquid penicillin has an unpleasant taste). The recommended dose is 40 mg/kg/day for 10 days. While the symptoms improve rapidly, it is crucial to complete the entire 10-day period of therapy. If compliance is in question, intramuscular benzathine penicillin G (0.6–1.2 million units) is the alternative. Erythromycin, cephalosporins, and clindamycin are excellent alternate choices for penicillin-allergic patients.

16 Do GABHS carriers need to be treated with antibiotics?

Carriers do not usually need to be treated. Up to 20% of school-aged children may be carriers of GABHS. They are at low risk for disease transmission or development of suppurative and nonsuppurative complications.

Bisno AL, Gerber MA, Gwaltney JM, et al: Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 35:113–125, 2002.

Gerber MA: Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am 52:729–747, 2005.

17 Should sore throat secondary to non-GABHS be treated?

There is not enough evidence in the literature to answer this question, and there are currently no clear recommendations on the necessity of treating these infections. In one report, children with group G β-hemolytic streptococci seem to have improved more quickly with oral penicillin. Group C is usually seen in older adolescents and young adults and is generally a milder illness than GABHS pharyngitis.

KEY POINTS: GABHS PHARYNGITIS

1 Accounts for 20–30% of pharyngitis in children

2 Presents with sore throat, red pharynx, tender submandibular lymph nodes

3 Absence of cough, coryza is characteristic

4 Penicillin or amoxicillin—still the drugs of choice for treatment

18 What is the current recommendation for tonsillectomy in patients with recurrent pharyngitis?

Tonsillectomy should be considered in patients with three or more episodes of pharyngitis per year for 3 consecutive years, or five episodes per year in 2 consecutive years, or seven episodes in 1 year despite adequate medical therapy.

Paradise JL, Bluestone CD, Colborn DK, et al: Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 110:7–11, 2002.

19 True or False: tonsillectomy affects the incidence and the course of pharyngitis.

False. The presence or absence of the tonsils has no bearing on the overall incidence or the course of the disease. However, after tonsillectomy, the frequency of streptococcal pharyngitis diminishes for 1–2 years, after which the incidence returns to that of the general population.

20 Are steroids helpful in treating pharyngitis?

Recent evidence suggests that a single dose of oral dexamethasone (Decadron) decreases time to onset of pain relief and recovery only in patients with moderate to severe pharyngitis. The greatest benefit was noted in patients with viral pharyngitis compared to those with bacterial pharyngitis.

Olympia RP, Khine H, Avner JR: Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Arch Pediatr Adolesc 159:278–282, 2005.

21 How soon can children with GABHS pharyngitis return to school or child care?

The American Academy of Pediatrics and recent studies recommend that children receive a full 24 hours of antibiotics before returning to school or child care.

American Academy of Pediatrics: Group A streptococcal infections. In Pickering L (ed): 2006 Redbook. Report of the Committee on Infectious Diseases, 27th ed. Elk Grove Village, IL, American Academy of Pediatrics, 2006, pp 610–620.

22 How can recurrent episodes of rheumatic fever be prevented?

If GABHS pharyngitis develops in a patient who has already had rheumatic fever in the past, he or she is at high risk for recurrent rheumatic fever. GABHS pharyngitis should therefore be prevented in any patient who has previously had rheumatic fever by administering continuous antibiotic prophylaxis. In most cases, intramuscular benzathine penicillin G every 4 weeks is preferred.

23 Can GABHS pharyngitis occur in children < 3 years of age?

Yes. Although it is a much more prevalent disease in school-aged children, it is a common myth that GABHS pharyngitis does not occur in younger children. Studies have reported disease rates between 5% and 25% in this age group. Rheumatic fever is very rare in these young children.

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