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You are in: eMedicine Specialties > Emergency Medicine > Ear, Nose, And Throat Rate this Article Pharyngitis Last Updated: April 21, 2005 Email to a Colleague Get CME/CE for article Synonyms and related keywords: infection of pharynx, irritation of pharynx, infection of tonsils, irritation of tonsils, group A beta-hemolytic streptococcal infections, GABHS infections, bacterial pharyngitis, viral pharyngitis, acute rheumatic fever, acute glomerulonephritis, upper respiratory infections, URIs, heart valve damage, Streptococcus pyogenes, rhinovirus, adenovirus, peritonsillar abscess, toxic shock syndrome, airway obstruction, Mycoplasma pneumoniae, Chlamydia pneumoniae, Arcanobacterium haemolyticus, rhinorrhea, gonococcal pharyngitis, coxsackievirus A, coxsackievirus B, herpes simplex, infectious mononucleosis, cytomegalovirus, CMV, odynophagia, tonsillopharyngeal petechiae, palatal petechiae, handfoot-and-mouth disease, cervical lymphadenopathy, acute lymphoglandular syndrome, hepatosplenomegaly, sandpapery scarlatiniform rash, maculopapular rashes, scarlet fever, meningitis, endocarditis, subdural empyemas, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Epstein-Barr virus, EBV, HIV-1, oral thrush, gastroesophageal reflux disease, GERD, smoking, endotracheal intubation, allergy, postnasal drip AUTHOR INFORMATION Section 1 of 10 Author Information Introduction Clinical Differentials Workup Treatment Medication Followup Miscellaneous Bibliography Author: Amin Antoine Kazzi, MD, Vice Chair, Associate Professor, Division of Emergency Medicine, University of California at Irvine Medical Center Coauthor(s): Jeannine Wills, MD, Staff Physician, University of California at Irvine College of Medicine Editor(s): Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Medical Director, Saint Barnabas Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center, Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and William K Mallon, MD, Program Director, Internship Training, Associate Professor, Department of Emergency Medicine, University of Southern California Disclosure INTRODUCTION Section 2 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Followup Miscellaneous Bibliography Background: Pharyngitis is defined as an infection or irritation of the pharynx and/or tonsils. The etiology is usually infectious, with 40-60% of cases being of viral origin and 5-40% of cases being of bacterial origin. Other causes include allergy, trauma, toxins, and neoplasia. The main ED concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A beta-hemolytic streptococcal (GABHS) infections. GABHS infections can have serious sequelae and represent approximately 15% of all ED pharyngitis visits. Pathophysiology: In infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response. Other viruses, such as rhinovirus, cause irritation of pharyngeal mucosa secondary to nasal secretion. Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases. In addition, M protein fragments of certain serotypes of GABHS are similar to myocardial sarcolemma antigens and are linked to rheumatic fever and subsequent heart valve damage. Acute glomerulonephritis may result from antibody-antigen complex deposition in glomeruli. Frequency: In the US: It has been estimated that children in the US experience over 5 upper respiratory infections (URIs) per year and an average of one streptococcal infection every 4 years. The occurrence in adults is about one half that rate. The most significant bacterial agent causing pharyngitis in both adults and children is GABHS infection ( Streptococcus pyogenes), and the most significant viruses are rhinovirus and adenovirus. GABHS is most prevalent in late fall through early spring. Internationally: The incidence is higher internationally. Antibiotic resistance may be more prevalent in some countries because of overprescription of antibiotics. In Japan, a 60% resistance rate to erythromycin is reported.

Mortality/Morbidity: One in 400 cases of untreated GABHS infections can be expected to result in acute rheumatic fever. Other sequelae of a streptococcal pharyngitis include acute glomerulonephritis, peritonsillar abscess, and toxic shock syndrome. Mortality from pharyngitis is rare but may result from one of its complications. For the ED physician, airway obstruction is a concern.

Age: Pharyngitis occurs with much greater frequency in the pediatric population. GABHS also is more common in school-aged children. GABHS causes 15% of all adult pharyngitis and about

30% of pediatric cases. The peak incidence of bacterial and viral pharyngitis occurs in the school-aged child aged 4-7 years. Pharyngitis, especially GABHS infection, is rare in children younger than 3 years. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus peak as causative agents in people in the teen years through the young adulthood years. CLINICAL Section 3 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Followup Miscellaneous Bibliography History: A clinical diagnosis of GABHS infection results in an overestimation of incidence by as much as 80%. Many bacterial and viral cases of pharyngitis can be indistinguishable on clinical grounds. However, the classic presentations are described below. GABHS infection most commonly occurs in those aged 4-7 years. Sudden onset is consistent with a GABHS pharyngitis. Pharyngitis following several days of coughing or rhinorrhea is more consistent with a viral etiology. Person recently has been in contact with others diagnosed with GABHS or rheumatic fever. Headache is consistent with GABHS or mycoplasma infection. Cough is not usually associated with GABHS infection. Vomiting is associated with GABHS infection but may be present in other types of pharyngitis. A history of recent orogenital contact suggests the possibility of gonococcal pharyngitis. o Physical: Airway patency must be addressed first. Temperature o Fever is usually absent or low-grade in viral pharyngitis, but this is not specific enough to differentiate viral and bacterial etiologies. Fever can be as high as 106F with coxsackievirus A, coxsackievirus B, herpes A history of rheumatic fever is important when considering treatment.

simplex, GABHS infection, HIV-1, infectious mononucleosis, and cytomegalovirus (CMV). Hydration status: Oral intake usually is compromised because of odynophagia; therefore, various degrees of dehydration result. HEENT o o o o Conjunctivitis may be seen in association with adenovirus. Scleral icterus may be seen with infectious mononucleosis. Rhinorrhea usually is associated with a viral cause. Tonsillopharyngeal/palatal petechiae are seen in GABHS infections and infectious mononucleosis. A tonsillopharyngeal exudate may be seen in streptococcal infectious mononucleosis and occasionally in M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infections. Therefore, exudate does not differentiate viral and bacterial causes. Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus. Concomitant vesicles on the hands and feet are associated with coxsackievirus (hand-foot-and-mouth disease).

Lymphadenopathy: Tender anterior cervical nodes are consistent with streptococcal infection, while generalized adenopathy is consistent with infectious mononucleosis or the acute lymphoglandular syndrome of HIV infection. Cardiovascular: Murmurs should be documented in an acute episode of pharyngitis to monitor for potential rheumatic fever. Pulmonary: Pharyngitis and lower respiratory tract infections are more consistent with M pneumoniae or C pneumoniae, particularly when a persistent nonproductive cough is present. Abdomen: Hepatosplenomegaly can be found in infectious mononucleosis infection. Skin o o A sandpapery scarlatiniform rash is seen in GABHS infection (see Scarlet Fever). Maculopapular rashes are seen with various viral infections and with infectious mononucleosis empirically treated with penicillin.

Causes: Bacterial pharyngitis

Group A beta-hemolytic streptococci (15% of all pharyngitis) The classic clinical picture includes a fever of greater than 101.5F, tonsillopharyngeal erythema and exudate, swollen tender anterior cervical adenopathy, elevated WBC count, headache, emesis in children, palatal petechiae, midwinter to early spring season, and absent cough or rhinorrhea, which are associated with viral pharyngitis. A scarlatiniform rash also is associated with GABHS infection (scarlet fever), ie, a sandpaperlike erythematous rash over the trunk and extremities with circumoral pallor and a strawberry tongue. Group C, G, and F streptococci (10%) may be indistinguishable clinically from GABHS infection but do not cause the immunologic sequelae of GABHS infection. They may be associated with food-borne outbreaks. Group C streptococci have been reported to cause meningitis, endocarditis, and subdural empyemas. Arcanobacterium (Corynebacterium) haemolyticus (5%) is more common in young adults and is very similar to GABHS infection, including a similar scarlatiniform rash. Patients often have a cough. Occasional outbreaks have been reported. Mycoplasma pneumoniae in young adults presents with headache, pharyngitis, and lower respiratory symptoms. Approximately 75% of patients have a cough, which is distinctive from GABHS infection. Chlamydia pneumoniae (5%) has a clinical picture similar to that of M pneumoniae. Pharyngitis usually precedes the pulmonary infection by about 1-3 weeks. Neisseria gonorrhoeae is a rare cause of pharyngitis. A careful history is important since infection usually follows orogenital contact. It may be associated with severe systemic infection. Corynebacterium diphtheriae is rare in the United States. A foul smelling graywhite pharyngeal membrane may result in airway obstruction. Unusual bacteria that could present with pharyngitis include Borrelia species, Francisella tularensis, Yersinia species, and Corynebacterium ulcerans.

Viral pharyngitis o Adenovirus (5%): The distinguishing feature of an adenovirus infection is conjunctivitis associated with pharyngitis (pharyngoconjunctival fever). It is the most common etiology in children younger than 3 years. Herpes simplex (< 5%): Vesicular lesions (herpangina), especially in young children, are the hallmark. In older patients, pharyngitis may be indistinguishable from GABHS infection. Coxsackieviruses A and B (< 5%): These infections present similarly to herpes simplex and also may have vesicles. If vesicles are whitish and nodular, it is known as lymphonodular pharyngitis. Coxsackie A16 may cause hand-foot-andmouth disease, which presents with 4- to 8-mm oropharyngeal ulcers and vesicles

on the hands and feet, and, occasionally, on the buttocks. The oropharyngeal ulcers and vesicles resolve within one week. o Epstein-Barr virus (EBV): Clinically known as infectious mononucleosis, it is extremely difficult to distinguish from GABHS infection. Exudative pharyngitis is prominent. Distinctive features include retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be seen on peripheral blood smear. Viral cultures from washings are about 20% sensitive in adults. CMV: Presentation of CMV is similar to the presentation of infectious mononucleosis. Patients tend to be older, are sexually active, and have higher fever and more malaise. Pharyngitis may not be a prominent complaint. HIV-1: This is associated with pharyngeal edema and erythema, common aphthous ulcers, and a rarity of exudates. Fever, myalgia, and lymphadenopathy also are found.

Other causes of pharyngitis o Oral thrush is due to candidal species, usually in patients who are immunocompromised. It may be common in young children and presents with whitish plaques in the oropharynx. o Other causes include dry air, allergy/postnasal drip, chemical injury, gastroesophageal reflux disease (GERD), smoking, neoplasia, and endotracheal intubation. Section 4 of 10

DIFFERENTIALS

Author Information Introduction Clinical Differentials Workup Treatment Medication Followup Miscellaneous Bibliography Candidiasis Diphtheria Epiglottitis, Adult Gonorrhea Herpes Simplex Mononucleosis Pediatrics, Croup or Laryngotracheobronchitis Pediatrics, Epiglottitis Pediatrics, Hand-Foot-and-Mouth Disease Pediatrics, Pharyngitis Pediatrics, Scarlet Fever Peritonsillar Abscess Pharyngitis Pneumonia, Mycoplasma Retropharyngeal Abscess Rheumatic Fever

Other Problems to be Considered: Allergic rhinitis with postnasal drip Airway obstruction Head and neck neoplasias

Gastroesophageal reflux disease (GERD) Peritonsillar cellulitis

WORKUP

Section 5 of 10

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography Lab Studies: GABHS rapid antigen detection test o This is the preferred method for diagnosing GABHS infection in the ED because of difficulties with culture follow-up. A throat swab should follow a negative result. Rapid antigen detection is not sensitive for Group C and G streptococci or other bacterial pathogens.

o o

Throat culture o o This is the criterion standard for diagnosis of GABHS infection (90-99% sensitive). Positive cultures are clinically important only in patients with a related clinical illness less than 10 days old.

Antistreptolysin-O (ASO) is a highly sensitive test but it is not practical in the ED because of the need for acute and convalescent titers. Mono spot is up to 95% sensitive in children (less than 60% sensitivity in infants). Peripheral smear may show atypical lymphocytes in infectious mononucleosis. Perform gonococcal culture, as indicated by history. Routine labs usually are not available for A hemolyticus, M pneumoniae, or C pneumoniae. Fluorescent monoclonal antibody test exists for C pneumoniae. A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein have a low predictive value and usually are not indicated.

Imaging Studies: Imaging studies generally are not indicated for uncomplicated viral or streptococcal pharyngitis. Lateral neck film should be taken in patients with suspected epiglottitis or airway compromise. A chest x-ray can elucidate pneumonia in M pneumoniae or C pneumoniae infection or in