Background
Viral pharyngitis can be caused by numerous viruses. 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. [1]
Most cases are caused by viruses and occur as part of common colds and influenzal syndromes.
For information on bacterial pharyngitis, see Bacterial Pharyngitis.
Pathophysiology
Several viruses can cause viral pharyngitis. [1, 2]
Rhinovirus
More than 100 different serotypes of rhinovirus cause approximately 20% of cases of pharyngitis and 30-50% of common colds. These viruses enter the body through the ciliated epithelium that lines 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. [2, 3]
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. 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 infectious mononucleosis.
Herpes simplex virus
Herpes simplex virus (HSV) types 1 and 2 cause gingivitis, stomatitis, and pharyngitis. Acute herpetic pharyngitis is the most common 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 develop 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. In the wake of COVID-19 pandemic, pharyngitis due to severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] becomes very common, and it can occur with or without other symptoms of COVID-19. SARS-CoV-2 infection enters the host cells through the S spike protein by binding to angiotensin converting enzyme 2 (ACE2).2 Mutations in the receptor binding domain and acquisition of a cleavage site in the S spike protein are responsible for high infectivity of this virus. [4]
Enterovirus
The major groups of enteroviruses that can cause pharyngitis are coxsackievirus and echovirus. Although enteroviruses are primarily are 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 human 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.
Epidemiology
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. Approximately 50-80% of pharyngitis symptoms are caused by a variety of viral pathogens. [1]
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 and 1996. The vast 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. For more information on pediatric pharyngitis, see Pediatric Pharyngitis.
