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Pharyngitis
MIRIAM T. VINCENT, M.D., M.S., NADHIA CELESTIN, M.D., and ANEELA N. HUSSAIN, M.D.
State University of New York–Downstate Medical Center, Brooklyn, New York
Sore throat is one of the most common reasons for visits to family physicians. While
most patients with sore throat have an infectious cause (pharyngitis), fewer than 20
percent have a clear indication for antibiotic therapy (i.e., group A beta-hemolytic strep-
tococcal infection). Useful, well-validated clinical decision rules are available to help
family physicians care for patients who present with pharyngitis. Because of recent
improvements in rapid streptococcal antigen tests, throat culture can be reserved for
patients whose symptoms do not improve over time or who do not respond to antibiot-
ics. (Am Fam Physician 2004;69:1465-70. Copyright© 2004 American Academy of Family
Physicians.)
P
Members of various haryngitis is one of the most marily by viruses or bacteria.4 GABHS phar-
family practice depart- common conditions encoun- yngitis accounts for 15 to 30 percent of cases
ments develop articles
for “Problem-Oriented
tered by the family physician.1-5 in children and 5 to 15 percent of cases in
Diagnosis.” This article The optimal approach for dif- adults.5,6,9,10 Sore throat also may be caused
is one in a series coor- ferentiating among various by other conditions, such as gastroesophageal
dinated by the Depart- causes of pharyngitis requires a problem- reflux, postnasal drip secondary to rhinitis,
ment of Family Practice focused history, a physical examination, and persistent cough, thyroiditis, allergies, a for-
at the State University
of New York–Down-
appropriate laboratory testing. Identifying eign body, and smoking.1,2,11
state Medical Center, the cause of pharyngitis, especially group A This article focuses on infectious causes of
Brooklyn. Guest editor beta-hemolytic streptococcus (GABHS), is sore throat (pharyngitis). If patients do not
of the series is Miriam important to prevent potential life-threaten- have any other signs of infection or do not
T. Vincent, M.D., M.S. ing complications.6 respond as expected to treatment of pharyn-
gitis, physicians should investigate noninfec-
Epidemiology and Pathogenesis tious causes.
The 2000 National Ambulatory Medical
Care Survey found that acute pharyngitis VIRUSES
accounts for 1.1 percent of visits in the pri- Viral pharyngitis, the most common cause
mary care setting and is ranked in the top 20 of sore throat, has a wide differential. Fur-
reported primary diagnoses resulting in office thermore, different viruses are more prevalent
visits.3 Peak seasons for sore throat include during certain seasons.4 Coryza, conjunctivi-
late winter and early spring.4 Transmission of tis, malaise or fatigue, hoarseness, and low-
typical viral and GABHS pharyngitis occurs grade fever suggest the presence of viral phar-
mostly by hand contact with nasal discharge, yngitis.12 Children with viral pharyngitis also
rather than by oral contact.7,8 Symptoms can present with atypical symptoms, such as
develop after a short incubation period of 24 mouth-breathing, vomiting, abdominal pain,
to 72 hours. and diarrhea.8,12
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Complications of GABHS Infection. The inci-
Patients with untreated streptococcal pharyngitis are infectious dence of complications with GABHS infec-
during the acute phase and for one additional week. tion, such as rheumatic fever and peritonsillar
abscess, is much lower than generally per-
ceived.17 Peritonsillar abscess occurs in fewer
than 1 percent of patients treated with antibi-
tosplenomegaly also may be present.10-12 If otics.1 Patients with peritonsillar abscess typi-
these patients are treated with amoxicillin or cally have a toxic appearance and may present
ampicillin, 90 percent will develop a classic with a “hot potato voice,” fluctuant periton-
maculopapular rash.14,15 sillar mass, and asymmetric deviation of the
uvula. However, clinical impression is only
BACTERIA moderately accurate in diagnosing peritonsil-
Patients with bacterial pharyngitis generally lar abscess (78 percent sensitivity and 50 per-
do not have rhinorrhea, cough, or conjuncti- cent specificity in one series of 14 patients).20
vitis. The incidence of bacterial pharyngitis is Intraoral ultrasound examination is an accu-
increased in temperate climates during winter rate diagnostic test if abscess is suspected.
and early spring.16 There is often a history of Rheumatic fever is exceedingly rare in the
streptococcal throat infection (strep throat) United States and other developed coun-
within the past year. GABHS is the most com- tries (annual incidence less than one case per
mon bacterial cause of pharyngitis.16-18 100,000).21 This illness should be suspected
GABHS Infection. Symptoms of strep throat in any patient with joint swelling and pain,
may include pharyngeal erythema and swelling, subcutaneous nodules, erythema marginatum
tonsillar exudate, edematous uvula, palatine or heart murmur, and a confirmed strepto-
petechiae, and anterior cervical lymphadenopa- coccal infection during the preceding month.
thy. Untreated, GABHS infection lasts seven Patients will have an elevated antistreptolysin-
to 10 days.4,13,19 Patients with untreated strep- O titer and erthrocyte sedimentation rate.
tococcal pharyngitis are infectious during the Poststreptococcal glomerulonephritis is
acute phase of the illness and for one additional another rare complication of GABHS phar-
week.1 Effective antibiotic therapy shortens the yngitis, although treatment with antibiotics
infectious period to 24 hours, reduces the dura- does not prevent it. Patients present with
tion of symptoms by about one day, and pre- hematuria and, frequently, edema in the set-
vents most complications. ting of a recent streptococcal infection with an
elevated antistreptolysin-O titer.
Scarlet fever is associated with GABHS
The Authors pharyngitis and usually presents as a punc-
MIRIAM T. VINCENT, M.D., M.S., is professor and chair of the Department of Family tate, erythematous, blanchable, sandpaper-
Practice at State University of New York (SUNY)–Downstate Medical Center, Brooklyn.
She is currently a doctoral thesis candidate in anatomy and cell biology.
like exanthem. The rash is found in the neck,
groin, and axillae, and is accentuated in body
NADHIA CELESTIN, M.D., is clinical assistant professor in the Department of Family
Practice at SUNY–Downstate Medical Center. She completed her residency training
folds and creases (Pastia’s lines).1,4,19 The phar-
and a faculty development fellowship in family medicine at SUNY–Downstate. ynx and tonsils are erythematous and covered
ANEELA N. HUSSAIN, M.D., is assistant professor in the Department of Family Practice
with exudates. The tongue may be bright red
at SUNY–Downstate Medical Center. Dr. Hussain completed her residency in family with a white coating (strawberry tongue).4
practice as chief resident at SUNY–Downstate. Other Bacterial Causes of Pharyngitis. Gono-
Address correspondence to Miriam T. Vincent, M.D., M.S., Department of Family Prac- coccal pharyngitis occurs in sexually active
tice, SUNY–Downstate, 450 Clarkson Ave., Box 67, Brooklyn, NY 11203-2098 (e-mail: patients18 and presents with fever, severe sore
mvincent@downstate.edu). Reprints are not available from the authors.
throat, dysuria, and a characteristic greenish
exudate.
1466-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 6 / MARCH 15, 2004
Pharyngitis
MARCH 15, 2004 / VOLUME 69, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1467
TABLE 1
Selected Laboratory Tests for Identifying the Cause of Pharyngitis
1468-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 6 / MARCH 15, 2004
TABLE 2 Pharyngitis
Streptococcal Score Validated
in Adults and Children
Symptom Points
MARCH 15, 2004 / VOLUME 69, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1469
Pharyngitis
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The authors indicate that they do not have any Hasselt CA. Diagnosis of peritonsillar infections:
conflicts of interests. Sources of funding: none a prospective study of ultrasound, computerized
reported. tomography and clinical diagnosis. J Laryngol Otol
1999;113:229-32.
21. Olivier C. Rheumatic fever—is it still a problem?
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