AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Acute pharyngitis is an inflammatory syndrome of the pharynx and/or tonsils caused by several different groups of microorganisms. Pharyngitis can be part of a generalized upper respiratory tract infection or a specific infection localized in the pharynx.

Most cases are caused by viruses and occur as part of common colds and influenzal syndromes.

Pathophysiology

Several viruses can be responsible for viral pharyngitis.

Rhinovirus

More than 100 different serotypes of rhinovirus cause approximately 20% of cases of pharyngitis and 30-50% of common colds. Viruses enter the body through the ciliated epithelium lining the nose, causing edema and hyperemia of the nasal mucous membranes. This condition leads to increased secretory activity of the mucous glands; swelling of the mucous membranes of the nasal cavity, eustachian tubes, and pharynx; and narrowing of nasal passages, causing obstructive symptoms. Bradykinin and lysyl-bradykinin are generated in the nasal passages of patients with rhinovirus colds, and these mediators stimulate pain nerve endings. The virus does not invade the pharyngeal mucosa. Transmission occurs by large particle aerosols or fomites.

Adenovirus

In children, adenovirus causes uncomplicated pharyngitis (most commonly caused by adenovirus types 1-3 and 5) or pharyngoconjunctival fever. The latter is characterized by fever, sore throat, and conjunctivitis. Unlike rhinovirus infections, adenovirus directly invades the pharyngeal mucosa, as shown by the viral cytopathic effect.

Epstein-Barr virus

Epstein-Barr virus (EBV) is the causal agent of infectious mononucleosis (IM). EBV usually spreads from adults to infants. Among young adults, EBV spreads through saliva and, rarely, through blood transfusion. In addition to edema and hyperemia of the tonsils and pharyngeal mucosa, an inflammatory exudate and nasopharyngeal lymphoid hyperplasia also develop. Pharyngitis or tonsillitis is present in about 82% of patients with IM.

Herpes simplex virus

Herpes simplex virus (HSV) types 1 and 2 cause gingivitis, stomatitis, and pharyngitis. Acute herpetic pharyngitis is the most frequent manifestation of the first episode of HSV-1 infection. After HSV enters the mucosal surface, it initiates replication and infects either sensory or autonomic nerve endings. The neurocapsid of the virus is intra-axonally transported to the nerve cell bodies in the ganglia and contiguous nerve tissue. The virus then spreads to other mucosal surfaces through centrifugal migration of infectious virions via peripheral autonomic or sensory nerves. This mode of spread explains the high frequency of new lesions distant from the initial crop of vesicles characteristic of oral-labial HSV infection.

Influenza virus

Pharyngitis and sore throat are present in about 50% of the patients with influenza A and in a lesser proportion of patients with influenza B. Severe pharyngitis is particularly common in patients with type A. The influenza virus invades the respiratory epithelium, causing necrosis, which predisposes the patient to secondary bacterial infection. Transmission of influenza occurs by aerosolized droplets.

Parainfluenza virus

Pharyngitis caused by parainfluenza virus types 1-4 usually manifests as the common cold syndrome. Parainfluenza virus type 1 infection occurs in epidemics, mainly in late fall or winter, while parainfluenza virus type 2 infection occurs sporadically. Parainfluenza virus type 3 infection occurs either epidemically or sporadically.

Coronavirus

Pharyngitis caused by coronavirus usually manifests as the common cold. As in rhinovirus colds, viral mucosal invasion of the respiratory tract does not occur.

Enterovirus

The major groups of enteroviruses that can cause pharyngitis are coxsackievirus and echovirus. Although enteroviruses are primarily transmitted by the fecal-oral route, airborne transmission is important for certain serotypes. Enteroviral lesions in the oropharyngeal mucosa are usually a result of secondary infection of endothelial cells of small mucosal vessels, which occurs during viremia following enteroviral infection in the GI tract.

Respiratory syncytial virus

Transmission of respiratory syncytial virus (RSV) occurs by fomites or large particle aerosols produced by coughing or sneezing. The pathogenesis of RSV infection remains unclear, although a number of theories exist. Immunologic mechanisms may contribute to the pathogenesis of the severe disease in infants and elderly patients.

Cytomegalovirus

Acute acquired cytomegalovirus (CMV) infection is transmitted by sexual contact, in breast milk, via respiratory droplets among nursery or day care attendants, and by blood transfusion. Infection in the immunocompetent host rarely results in clinically apparent disease. Infrequently, immunocompetent hosts exhibit a mononucleosislike syndrome with mild pharyngitis.

Human immunodeficiency virus

Pharyngitis develops in patients infected with human immunodeficiency virus (HIV) as part of the acute retroviral syndrome, a mononucleosislike syndrome that is the initial manifestation of HIV infection in one half to two thirds of recently infected individuals.

Frequency

United States

Each year, pharyngitis is responsible for more than 40 million visits to health care providers. Most children and adults experience 3-5 viral upper respiratory tract infections (including pharyngitis) per year.

International

Worldwide, acute infections of the respiratory tract are one of the main causes of disease, and most of these are due to viruses.

Mortality/Morbidity

Worldwide, viral pharyngitis is one of the most common causes of absence from school or work. The National Ambulatory Medical Care Survey showed that upper respiratory tract infections, including acute pharyngitis, accounted for 200 annual visits to a physician per 1000 population between 1980-1996. The overwhelming majority of upper respiratory tract infections are due to viruses.

Race

Viral pharyngitis affects all races and ethnic groups equally.

Sex

Viral pharyngitis affects both sexes equally.

Age

Viral pharyngitis affects both children and adults, but it is more common in children.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Sore throat is the chief complaint of patients with viral pharyngitis. Patients may have additional symptoms that vary with causal agents. These symptoms are generally not useful in discriminating between the causes of viral pharyngitis because the symptoms produced by the numerous viruses that cause pharyngitis are so similar and commonly overlap each other.

• Pharyngitis in the common cold syndrome: Sore throat is usually not the primary complaint. Nasal symptoms, such as sneezing, watery nasal discharge, nasal congestion, or postnasal discharge, tend to precede throat symptoms. Throat symptoms can be in the form of soreness, scratchiness, or irritation. Nasal discharge may be thick and yellow. Nonproductive cough may be present. Fever, if present, is usually low grade. Fever is more prominent in young children than in adults. Hoarseness is sometimes present. Severe pharyngeal pain or odynophagia are unusual. Chills, myalgia, and profound malaise are usually not prominent.
• Pharyngitis caused by adenovirus: Pharyngitis caused by adenovirus is common among young children and military recruits. Patients with pharyngitis present with sore throat that is more intense than that of a common cold, high fever, dysphagia, and red eyes. Red eyes are due to concurrent conjunctivitis, which occurs in one third to one half of affected patients, along with fever. This syndrome is named pharyngoconjunctival fever. The patient may have a history of swimming pool exposure approximately 1 week before onset of illness. Military personnel tend to be more ill with hoarseness, chest pain, and respiratory distress.
• Pharyngitis associated with IM: IM is most commonly observed in adolescents and young adults. Sore throat is the most common complaint of patients with IM. Prodromal symptoms of fatigue, malaise, myalgia, fever, chills, and sweats usually develop 1-2 weeks before the onset of sore throat. Pharyngeal symptoms are usually associated with other features of the disease (eg, headache, skin rash, anorexia, nausea, vomiting, abdominal pain).
• Acute herpetic pharyngitis: Acute herpetic pharyngitis is most commonly observed in children and young adults. Sore throat may be accompanied by sore mouth with associated gingivostomatitis. Other symptoms include fever, myalgia, malaise, inability to eat, and irritability.
• Pharyngitis with influenza: Sore throat is the chief complaint in some patients with influenza. The onset of illness is usually abrupt, with myalgia, headache, fever, chills, and dry cough. The pharyngitis usually resolves in 3-4 days. Cases generally occur in an epidemic pattern, usually in late fall or winter in North America.
• Pharyngitis caused by enteroviruses: Enteroviruses are an important cause of viral pharyngitis in childhood. This condition has a peak occurrence in late summer and early fall. Distinctive clinical syndromes include (1) herpangina caused by coxsackievirus A2-6; (2) acute lymphonodular pharyngitis caused by coxsackievirus A10; (3) hand-foot-and-mouth disease caused by coxsackievirus A5, 9, 10, and 16, and enterovirus 71; and (4) Boston exanthem caused by echovirus type 16.
• • Young children with herpangina have sore throat, sore mouth, and severe odynophagia. Sudden onset of fever (temperature of up to 106°F/41°C), coryza, and anorexia are common presenting complaints. Twenty-five percent of children vomit. Older children develop neck pain, headache, and back pain. Herpangina is not associated with gingivitis, in contrast to acute herpetic pharyngitis.
  • Acute lymphonodular pharyngitis is a variant of herpangina. Symptoms are similar to those of herpangina, and the condition is indistinguishable from herpangina by history.
  • Children with hand-foot-and-mouth disease have low-grade grade fever (temperature, 100-102°F/38-39°C), sore throat, sore mouth, anorexia, malaise, and rash on the hands and feet.
  • Children with Boston exanthem have sudden onset of fever, sore throat, nausea, and rash over the face and trunk.
• Pharyngitis caused by RSV: Immunocompetent adults with RSV infection present with nasal discharge, sore throat, low-grade fever, and cough. Infants, elderly persons, and patients with chronic obstructive pulmonary disease (COPD) or congestive heart failure are more likely to develop lower respiratory tract involvement, which manifests as dyspnea, wheezing, and respiratory failure. Outbreaks of illness occur during the fall, winter, and early spring.
• Pharyngitis caused by CMV: Patients who have CMV infection tend to be older and sexually active compared to those with IM. Sore throat is less salient, but fever and malaise are more prominent than in IM. Myalgia and arthralgia are also prominent.
• Pharyngitis caused by HIV: HIV produces acute sore throat similar to IM in primary HIV infection (acute retroviral syndrome). Sore throat is usually accompanied by other symptoms. Fever, sweats, malaise, lethargy, myalgias, anorexia, nausea, diarrhea, and skin rash are prominent symptoms.

Physical

Edema and erythema of the pharynx are typical in viral pharyngitis. The degree of erythema does not correlate with the degree of soreness. Exudate can be present but is generally less effusive than in bacterial pharyngitis.

• Pharyngitis in the common cold syndrome: Redness around the external nares from nose blowing may be noted. Nasal mucosa is often erythematous. Mild erythema of the pharynx is usually present.
• Pharyngitis caused by adenovirus: Examination of the oropharynx reveals pharyngeal erythema with exudates. When associated with conjunctivitis, both bulbar and palpebral conjunctivae are involved without purulent discharge. The palpebral conjunctivae usually have a granular appearance. Although the onset is frequently monocular, the other eye usually becomes involved. Conjunctivitis often persists after fever and other symptoms have resolved. Preauricular and cervical lymphadenopathy may be present.
• Pharyngitis associated with IM: Examination of the oral cavity and pharynx reveals the characteristic marked enlargement of the tonsils. Half of patients with IM have a coating of thick, continuous exudates, mimicking streptococcal pharyngitis. The uvula may also be swollen. Unilateral palatal swelling and tenderness may be present. Palatal petechiae may be observed in both IM and streptococcal pharyngitis. However, palatal petechiae associated with IM tend to be confined to the soft palate. Fever may reach a temperature of up to 104°F/40°C. Periorbital edema is common. Tender lymphadenopathy is most prominent in the posterior and anterior cervical regions, but axillary and inguinal nodes may also be enlarged. Splenomegaly is present in 50% of patients; hepatomegaly in approximately 10-15%; jaundice in 5%; and a fine, variable form rash in about 5%. More than 90% of patients given ampicillin develop a diffuse, pruritic maculopapular eruption.
• Acute herpetic pharyngitis: Examination of the oral cavity and pharynx shows characteristic painful, shallow ulcers with red margins or vesicles on the hard and soft palates, posterior pharynx, and tonsillar pillars. Exudates may be present on the lesions. These lesions can be present on the tongue, gingiva, lips, or buccal mucosa with an associated gingivostomatitis. Lesions on the tongue, gingiva, or buccal mucosa may appear late in the course in a third of cases. Fever and tender cervical lymphadenopathy are common. Fever may reach temperatures of up to 106°F/41°C in children younger than 5 years. Clinically differentiating acute herpetic pharyngitis from bacterial pharyngitis can be difficult.
• Pharyngitis with influenza: Edema and erythema of pharyngeal mucosa may be present but usually to a mild degree. Pharyngeal or tonsillar exudates and cervical lymphadenopathy are absent. Fever with temperatures of up to 104°F/40°C is common. Flushed face and conjunctival injection are usually prominent.
• Enteroviral pharyngitis
• • Herpangina is characterized by multiple small vesicles (1-2 mm) on the tonsils, tonsillar pillars, uvula, or soft palate. Vesicles may enlarge to 4 mm or have an erythematous ring as large as 10 mm. Vesicles become shallow ulcers in about 3 days and then heal. The remainder of the pharynx is usually normal.
  • Acute lymphonodular pharyngitis is characterized by the distribution of oropharyngeal lesions similar to herpangina. However, the lesions do not evolve into vesicles and ulcers. They remain papular and become grayish-white and nodular secondary to infiltration with lymphocytes. Hand-foot-and-mouth disease is characterized by 4- to 8-mm ulcers on the tongue, buccal mucosa, or, occasionally, tonsillar pillars. Vesicles develop on the hands and feet or, occasionally, on the buttocks.
  • Boston exanthem is characterized by pharyngeal erythema and a roseolalike salmon-pink maculopapular rash over the face and trunk.
• Pharyngitis caused by CMV: Physical findings in CMV mononucleosis syndrome are similar to those in IM except for less prominent pharyngeal signs. The pharynx may be mildly erythematous or almost normal in appearance. Splenomegaly is characteristic.
• Pharyngitis caused by HIV: Examination of the oral cavity and pharynx reveals tonsillar hypertrophy without exudate. Cervical, occipital, or axillary lymphadenopathy is a frequent manifestation; hepatosplenomegaly is less common. Oral aphthous ulcerations have been reported in several cases. A rash that may be maculopapular, roseolalike, or urticarial develops in 40-80% of patients.

Causes

• Rhinovirus and adenovirus are the most common etiological agents, and each accounts for 6-20% of all cases of pharyngitis, both viral and nonviral.
• Less common etiological agents include EBV, HSV, influenza virus, parainfluenza virus, and coronavirus.
• Uncommon etiological agents are enterovirus (eg, poliovirus, coxsackievirus, echovirus), RSV, CMV, rotavirus, reovirus, rubella virus, varicella-zoster virus, measles virus, and HIV-1.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Streptococcal pharyngitis
Gonococcal pharyngitis
Other bacterial pharyngitis
Peritonsillar abscess
Diphtheria
Pharyngeal candidiasis
Noninfectious pharyngitis (eg, allergies; environmental factors; psychosomatic sore throat; sore throat caused by excessive shouting, cheering, or singing; dryness of the throat caused by nasal blockade, obstructive sleep apnea, palatal dysfunction, or mouth breathing)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The similarity of signs and symptoms of viral pharyngitis make a specific etiological diagnosis virtually impossible without various laboratory tests. In many circumstances, etiological diagnosis is of no practical use because it may not alter the treatment and prognosis. Viral cultures are not needed to diagnose pharyngitis other than in a research setting.
• The total WBC count may initially be slightly elevated without bandemia, followed by a decrease to fewer than 5000 cells after 4-7 days of illness in about 50% of cases.
• Atypical lymphocytosis is frequently associated with viral pharyngitis. This condition is more prominent in IM, acute CMV infection, and acute retroviral syndrome.
• Results from a rapid streptococcal antigen test and a bacterial culture of throat swab are negative.
• Common cold: Specific virological diagnosis is unnecessary for practical purposes because it may not alter the management. Cultures of nasal secretions, serological tests, and polymerase chain reaction (PCR) techniques can be used for specific virological diagnosis. Rapid viral antigen detection tests are not sensitive enough to be useful.
• IM: A peripheral blood film reveals relative and absolute lymphocytosis, with more than 10% atypical lymphocytes. Hemolytic anemia and thrombocytopenia secondary to anti-i antibodies are occasionally observed. Liver function test results are abnormal in about 90% of cases. Heterophile agglutination test (immunoglobulin M [IgM] antibody) results are positive with a titer of 40-fold or greater in 90% of affected adolescents and adults within the first few weeks after the onset of IM symptoms. A mononucleosis spot test (Monospot) allows rapid screening for heterophile antibodies. Heterophile test results are usually negative in children younger than 4 years. Positive results for IgM antibody to viral capsid antigen and positive results for antibody to early antigen are useful to diagnose acute infection, particularly in cases that are heterophile negative.
• Influenza: Leukopenia and proteinuria are nonspecific findings in influenza. Virus isolation or detection of viral antigen in respiratory secretions is very useful to diagnose acute illness. Virus can be readily isolated from nasal swab specimens, throat swab specimens, nasal washes, or combined nose-and-throat swab specimens by inoculation of embryonated eggs or cell cultures. Rapid detection of viral antigen directly in respiratory secretions can be accomplished by immunofluorescent (IF) studies, time-resolved immunofluorescence assay (TRFIA), radioenzyme immunoassay, and enzyme-linked immunosorbent assay (ELISA).

  PCR techniques have been described for rapid detection of influenza virus RNA in clinical samples. Serological tests can be used, but they are not helpful for diagnosis and treatment of acute disease secondary to delay in obtaining the antibody titers in convalescent sera. Serological tests are useful for epidemiological purposes. A rise in complement-fixing and hemagglutination-inhibiting antibody levels during the second week is considered diagnostic of acute infection.

• Enterovirus infection: Positive results on an enteroviral-specific reverse transcriptase-polymerase chain reaction (RT-PCR) test of throat swabs are diagnostic. Etiological diagnosis is not necessary for clinical purposes because it may not alter treatment.
• RSV infection: RSV antigen in nasal secretions can be reliably detected with commercially available rapid tests.
• CMV infection: A relative lymphocytosis is characteristic of acute CMV pharyngitis. Atypical lymphocytes may represent 10% or more of the total. CMV can be readily isolated from a throat swab. Positive results on the CMV-specific IgM antibody titers are diagnostic of acute infection. Results of heterophile tests are usually negative (heterophile-negative mononucleosis syndrome). A 4-fold or greater rise in antibody titers is confirmatory but useful only for epidemiological purposes.
• Acute retroviral syndrome (primary HIV infection): Serological test results for HIV are usually negative during the phase of acute retroviral syndrome because the test takes approximately 4 weeks for seroconversion. HIV RNA assay by PCR technique and p24 antigen assay can be used to help confirm the diagnosis. HIV viral load is usually extremely high. The peripheral blood picture may resemble IM. Heterophile test results are usually negative (heterophile-negative mononucleosis syndrome).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Rest, oral fluids, and salt-water gargling (for soothing effect) are the main supportive measures.
• Analgesics and antipyretics may be used for relief of pain or pyrexia. Acetaminophen is the drug of choice. Traditionally, aspirin has been used, but it may increase viral shedding. Do not use aspirin in children and adolescents because of its association with Reye syndrome, especially with influenza. One study proved that ibuprofen was superior to acetaminophen for symptomatic relief in children aged 6-12 years.
• Anesthetic gargles and lozenges, such as benzocaine, may be used for symptomatic relief.
• Hospitalization for intravenous hydration may be necessary when odynophagia is intense.
• Antibiotics do not hasten recovery or reduce the frequency of bacterial complications.
• Specific treatment of viral infections is available for only a few viruses.
• Influenza
• • Beginning treatment with amantadine or rimantadine within 48 hours of the onset of illness decreases the duration of symptoms in influenza A infection. However, both agents lack activity against influenza B infection, which is usually mild.
  • Amantadine and rimantadine are recommended for cases of presumed influenzal pharyngitis occurring during a known influenza type A epidemic. The major advantage of rimantadine is a low-risk risk of central nervous system effects, such as lightheadedness, difficulty concentrating, nervousness, and insomnia, which can be a significant problem with amantadine, particularly in elderly patients. Amantadine and rimantadine are not recommended by the CDC for the 2005-2006 influenza season because of resistance. Laboratory testing by CDC on the predominant strain of influenza (H3N2) currently circulating in the United States shows that it is resistant to these drugs.
  • Ribavirin has helped patients severely ill with influenza A or B infections.
  • Newer neuraminidase inhibitors, inhaled zanamivir, and oral oseltamivir started within 30 hours of the onset of influenza can shorten the duration of symptoms and, possibly, decrease the rate of complications. Neuraminidase inhibitors appear to be active against all strains of influenza A and B, although resistance to these agents can occur.
• Infectious mononucleosis
• • Specific antiviral therapy with acyclovir, ganciclovir, and interferon alfa reduces viral shedding but does not improve clinical outcome.
  • Corticosteroids may improve the symptoms, but they are generally not recommended because IM is usually benign and self-limited.
  • However, corticosteroids are indicated if the patient has tonsillar hypertrophy that threatens to obstruct the airway.
• Herpes simplex virus
• • In an immunocompetent host, oral acyclovir, famciclovir, and valacyclovir decrease the duration of symptoms and viral shedding.
  • In an immunocompromised host, these drugs decrease pain and viral shedding and accelerate healing of lesions. These drugs are helpful in severely afflicted patients.
• Acute retroviral syndrome
• • Several unique considerations favor antiretroviral therapy during this phase of HIV infection. Treatment may limit the extent of viral dissemination throughout the body, attenuate the progress of HIV infection by lowering the plasma viral RNA set point, and limit the extent of viral genetic variability, which is responsible for drug resistance.
  • Treatment may also allow salvage of a CD4 T-cell–specific immune response that may be important in the immune control of HIV infection.

Diet

Drinking large amounts of fluid is recommended. No specific dietary restrictions are needed. Soft, cold foods (eg, ice cream, popsicles) are more easily tolerated.

Activity

No restriction in activity is required.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Analgesics/antipyretics

Often helpful in relieving the pain and fever associated with pharyngitis.

Drug Category: Topical anesthetics

Soothe irritated or inflamed mucous membranes associated with sore throat.

Drug Category: Antiviral agents

Specific treatment of viral infections. Available for only a few viruses.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Deterrence/Prevention

• Washing hands frequently, using disposable tissues, and limiting human contact are important preventive measures for the common cold syndrome and other viral pharyngitis. No consistent benefit was demonstrated in preventing a common cold with large doses of vitamin C.
• Live adenovirus vaccines have been successfully used in military populations but are not available for civilian use.
• Administration of influenza vaccine to high-risk individuals and those who want to prevent influenza is the major preventive measure. Amantadine may be used to prevent influenza A during outbreaks.

Complications

• The complication rate of viral pharyngitis associated with a common cold is quite low. Purulent bacterial otitis media and sinusitis may occur.
• IM may be complicated by tonsillar and peritonsillar abscess, necrotic epiglottitis, airway obstruction, hepatic dysfunction, splenic rupture, hypersplenism, encephalitis, pneumonitis, pericarditis, and hematologic disorders.
• Herpetic pharyngitis may lead to necrotizing tonsillitis, epiglottitis, and recurrent disease.
• Influenza may be complicated by secondary bacterial pneumonia. Pneumococcal pneumonia is most common. Staphylococcal pneumonia is most serious.
• RSV infection, particularly in infants, elderly persons, and patients with underlying COPD, may be complicated by pneumonia and respiratory failure.
• Complications of HIV infection are beyond the scope of this article.

Prognosis

• The prognosis of a patient with a common cold is excellent. Most adults recover in less than a week, and most children in less than 2 weeks.
• In patients with IM, fever disappears in approximately 10 days. Lymphadenopathy and splenomegaly disappear in approximately 4 weeks. Debility sometimes remains for approximately 2-3 months, and the condition is occasionally fatal because of splenic rupture, hypersplenism, or encephalitis.
• The duration of uncomplicated influenza is 1-7 days. Prognosis is excellent. Most fatalities are due to secondary bacterial pneumonia.
• Enteroviral pharyngitis is usually benign and self-limited.

Patient Education

• Patient education should emphasize the natural course of viral infection and that it takes several days to feel better. Patients must understand that antibiotics are not needed for sore throats of viral origin. Risk of allergic reactions, fungal superinfection, and bacterial resistance should be discussed.
• Patients should be reassured that certain measures, including pain relievers, throat sprays or lozenges, and gargling with warm salt water, improve symptoms without antibiotics.
• Fever persisting for more than 5 days, extreme throat pain causing dysphagia, inability to open the mouth wide, or fainting spells when standing should prompt a visit to a doctor.
• For excellent patient education resources, visit eMedicine's Cold and Flu Center, Bacterial and Viral Infections Center and Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Colds, Sore Throat, Mononucleosis, and Tonsillitis.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The major role of the clinician in evaluating viral pharyngitis is to distinguish pharyngitis caused by different viruses from that caused by group A beta hemolytic streptococcus (GABHS) because the latter may lead to serious sequelae such as rheumatic fever and poststreptococcal glomerulonephritis.
• Differentiating streptococcal from viral pharyngitis is important because of the response of streptococcal infection to penicillin therapy and the ineffectiveness of antibiotic therapy in the viral infections.
• Absence of fever or the presence of clinical features, such as conjunctivitis, cough, hoarseness, coryza, anterior stomatitis, discrete ulcerative lesions, viral exanthem, and diarrhea, strongly suggests a viral rather than streptococcal etiology.
• Although a throat swab is commonly recommended to confirm or exclude streptococcal pharyngitis, the test's sensitivity and specificity are somewhat low (26-30% and 73-80%, respectively) compared to the criterion standard of a rise in antistreptolysin O titer. The high asymptomatic carrier rate of GABHS is probably responsible for the low predictive value of throat swabs. The rapid antigen detection test (RADT) is even less sensitive than throat cultures.
• The rationale behind treating people with pharyngitis with antibiotics is to reduce the symptoms and the likelihood of developing complications if the condition is streptococcal in etiology. Conversely, prescribing antibiotics to everyone has some disadvantages, including, but not limited to, adverse effects of antibiotics, direct costs of antibiotics, and the impact on bacterial resistance.
• Practice guidelines from the Infectious Disease Society of America (IDSA) and Standing Medical Advisory Committee of United Kingdom recommend prescribing antibiotics in patients in whom GABHS has been identified. Unfortunately, no satisfactory diagnostic test is available that can identify such patients in a timely manner.
• Earlier scoring systems attempting to identify the streptococcal infection among patients presenting with pharyngitis correlated poorly with microbiological data. In Canada, a sore throat score based on clinical symptoms and signs for identification of streptococcal infection has been developed and validated in children and adults. An explicit clinical score approach to the management of patients with pharyngitis could substantially reduce unnecessary prescribing of antibiotics for viral pharyngitis.
• A multicriteria decision analysis using the Analytic Hierarchy Process (AHP) was recently conducted to help clinicians better understand the differences between the conflicting guidelines on initial approach in a patient with pharyngitis. The AHP is one of several multicriteria decision-analysis methods designed to help people make better decisions in complex situations that involve tradeoffs between the advantages and disadvantages of several alternatives. The results of the AHP analysis suggest that decisions about management of adults with sore throat should incorporate both clinical estimates of the likelihood of a group A streptococcal infection and the priorities assigned to pertinent decision criteria by those affected by the decision. Additional research, however, is needed to establish the criteria to define quality management of adults who present with pharyngitis.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bisno AL. Acute pharyngitis. N Engl J Med. Jan 18 2001;344(3):205-11. [Medline].
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Article Last Updated: May 26, 2006