• Information
  1. Causes
  2. Streptococcal Pharyngitis
  3. Other Treatment

A. Causes

1. Respiratory Viruses (most common)
   1. Rhinovirus ~20% of cases
   2. Coronavirus ~5% of cases
   3. Adenovirus ~5% of cases (often with conjuctivitis)
   4. Coxsackie viruses - often with vesicles and ulcers on tonsillar pillars and soft palate
   5. Influenza Types A and B
   6. Parainfluenza
   7. RSV
   8. Herpes Simplex Virus Types 1 and 2
   9. Epstein-Barr Virus (EBV) - mononucleosis syndrome
   10. Acute retroviral syndrome (HIV infection)
2. Bacterial
   1. Streptococcal ssp. - 10-15% of adult cases with positive throat cultures (Groups A,C,G)
   2. Group A streptococcus (S. pyogenes) is most common (15-30%)
   3. N. gonorrhea - orogenital sexual contact
   4. H. influenza - Type B especially in children; untypable mainly in adults
   5. Diphtheria - caused by Corynebacterium diphtheriae - mainly in unimmunized persons
   6. Symptoms of diphtheria include dysphagia, neck edema common
   7. M. pneumoniae - rare pharyngitis without pneumonia
   8. Arcanobacterium haemolyticum - rare cause of acute pharyngitis and tonsillitis
   9. Miscellaneous - meningococci, M. tuberculosis, Yersinia enterocolitica, T. pallidum
   10. Deep pharyngeal abscess with single or mixed organisms can develop [11]
3. Candida albicans
   1. Especially in immunocompromised
   2. Increased incidence with use of inhaled glucocorticoids
   3. Diabetes
4. Other
   1. Trauma
   2. Irritants (smoke, chemicals)
   3. Dehydration
   4. Chronic cough - often post-nasal drip associated
   5. Vomiting
   6. Gastroesophageal Reflux (usually with laryngitis)

B. Streptococcal Pharyngitis [13]

1. Most often caused by group A, ß-hemolytic streptococcus
   1. Carrier rate in adults ~20%
   2. Responsible for ~10% of adult cases of pharyngitis [6]
2. Groups C and G may also be causative in humans
3. Clinical Presentation
   1. Acute onset of sore throat and odynophagia
   2. Pharyngeal and/or tonsillar erythema and exudate
   3. Cervical adenopathy
   4. Fever usually >101°F
   5. Rhinorrhea and myalgia uncommon
   6. Evaluate for signs of peritonsilar abscess [11]
   7. Difficult to distinguish streptococcal from viral and other pharyngitis
4. Clinical Factors Suggestive of Streptococcal Pharyngitis [2]
   1. Tonsillar exudate
   2. Pharyngeal exudate
   3. Exposure to strep throat infection within previous 2 weeks
   4. Clinical characteristics alone are not sufficient for definitive diagnosis [9]
5. Laboratory [10]
   1. Very rapid, office-based optical immunoassay is available (96% sens, 89% spec) [3]
   2. Throat culture should be obtained and is probably most cost effective
   3. Complete blood counts with differential should be obtained
   4. Mononucleosis should also be ruled out with monospot test
   5. Empirical treatment is not appropriate nor cost effective [10]
6. Complications
   1. Peritonsillar abscess
   2. Retropharyngeal abscess - especially if patient has a stiff neck
   3. Scarlet Fever
   4. Acute Rheumatic Fever
   5. Renal Dysfunction - glomerular disease
   6. Bronchitis / pneumonia
7. Renal Disease
   1. Acute, rapidly progressive glomerulonephritis
   2. Hematuria, red cell casts and proteinuria)
   3. Early antibiotic therapy may not prevent disease
8. Treatment [6,7]
   1. Penicillin (PCN) 250mg po qid x 10 days or1.2MU PCN benzathine IM x 1 preferred [6]
   2. Controversy over whether amoxicillin once daily is as effective as PCN bid-qid [4,5]
   3. PCN V twice daily is as effective as PCN given 3-4 times per day [4]
   4. Erythromycin 250mg qid x 10 days or azithromycin qd x 5 days for PCN allergy
   5. First generation cephalosporin for 10 days may be used in some patients in PCN allergy
   6. Ampicillin should be avoided because if patient has infectious mononucleosis then there is a high incidence (~95%) of rash
   7. Course of therapy must be maintained for 10 days for most oral agents
   8. Oral saline gargles offer symptomatic relief

C. Other Treatment

1. Supportive Care [6,7]
   1. Analgesics
   2. Antipyretics
   3. Should be offerred to all patients
   4. Glucocorticoids (prednisone 1mg/kg po qd x 2 days) reduce pain, is safe in adults [12]
2. Antibiotics are offerred to ~50% adults with sore throats, often inappropriately [8]
3. Mononucleosis
   1. Oral glucocorticoids to prevent airway compromise
   2. Glucocorticoids may also be used to decrease painful lymphadenopathy
   3. Prednisone 40mg po qd x 3-5 d is usually given
   4. Avoid ampicillin (? amoxicillin) since patients with mononucleosis often develop a rash
4. Complicated Pharyngitis
   1. Concern for sinusitis, mastoiditis, meningitis
   2. Deep pharyngeal abscess - progressive disease with systemic symptoms [11]
   3. Higher doses of antibiotics for longer courses are required
5. Candida
   1. Oral mouthwashes - nystatin 5cc po swish + spit 4-6x/day or clotrimazole troche qid
   2. Fluconazole oral 200mg po qd - only if topical therapy fails
   3. Rinse mouth out well after using inhaled steroids
6. Gonococcus
   1. Single dose 250mg ceftriaxone im or
   2. Single oral dose of Cefixime (Suprax®) 400mg
7. Diphtheria - antitoxin. Prevents myocarditis and peripheral neuritis

References

1. Bisno AL. 2001. NEJM. 344(3):205
2. Ebell MH, Smith MA, Barry HC, et al. 2000. JAMA. 284(22):2912
3. Gerber MA, Tanz RR, Kabat W, et al. 1997. JAMA. 277(11):899
4. Lan AJ and Colford JM Jr. 2000. Pediatrics. 105:E19
5. Feder HMJ, Gerber MA, Randolph MF, et al. 1999. Pediatrics. 103:47
6. Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. 2001. Ann Intern Med. 134(6):506
7. Cooper RJ, Hoffman JR, Bartlett JG, et al. 2001. Ann Intern Med. 134(6):508
8. Linder JA and Stafford RS. 2001. JAMA. 286(10):1181
9. Bisno AL. 2003. Ann Intern Med. 139(2):150
10. Neuner JM, Hamel MB, Phillips RS, et al. 2003. Ann Intern Med. 139(2):113
11. Bliss SJ, Flanders SA, Saint S. 2004. NEJM. 350(10):1037
12. Kiderman A, Yaphe J, Bregman J, Furst AL. 2007. Brit J Gen Pract. 55(512):218
13. Schroeder BM. 2003. Am Fam Phys. 67(4):880