Bacterial Pharyngitis Clinical Presentation

  • Author: Eric S Halsey, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 11, 2012
 

History

The signs and symptoms listed below may be seen with many non-GABHS etiologies. Furthermore, individuals with GABHS pharyngitis may have only a few or mild features listed. Conjunctivitis, cough, hoarseness, coryza, diarrhea, anterior stomatitis, discrete ulcerative lesions, and a viral exanthem are all more consistent with an etiology other than GABHS.

  • Sore throat, usually with sudden onset
  • Odynophagia
  • Headache
  • Nausea, vomiting, and abdominal pain
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Physical

  • Fever
  • Tonsillopharyngeal erythema
  • Exudates (patchy and discrete)
  • Beefy red swollen uvula
  • Lymphadenopathy (tender anterior cervical nodes)
  • Petechiae on the palate
  • Scarlatiniform rash (In susceptible hosts, this usually manifests within the first two days of symptoms and causes a finely papular, blanching, and erythematous rash. The neck is often first affected and then spreads along the trunk and limbs. Resolution, often at 3-4 days, occurs in roughly the same order of appearance and often results in desquamation of the involved areas.)

Predictive models can help determine the likelihood of GABHS pharyngitis based on the presence of fever, swollen tender anterior cervical lymph nodes, and tonsillar exudates and the absence of cough. Scores have been used to distinguish which patients merit further laboratory evaluation or treatment. The use of such clinical algorithms has been the source of much debate.[14, 15]

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Causes

  • Viruses cause the vast majority of pharyngitis cases. Common agents include coronavirus, rhinovirus, adenovirus, parainfluenza, influenza, Epstein-Barr virus, cytomegalovirus, and HIV.
  • GABHS accounts for 15%-30% of pharyngitis cases in children and 5%-10% of cases in adults.[14]
  • The following are bacteria other than GABHS that may cause pharyngitis:
    • Group C and G streptococci: Like GABHS, these pathogenic bacteria cause beta-hemolysis, form large colonies, and produce an M protein, yet neither are detected with rapid antigen detection tests (RADTs). Pharyngitis caused by either of these non-GABHS streptococci have a clinical presentation similar to that of GABHS pharyngitis and should be considered in patients with worsening symptoms and an initial negative RADT result. Diagnosis can be achieved with a normal bacterial throat culture and identification based on Lancefield antigens.[16] These bacteria are an uncommon cause of acute pharyngitis in pediatric patients.[17, 18]
    • Arcanobacterium haemolyticum: This gram-positive rod accounts for between 0.5% and 3% of pharyngitis cases.[19] Clinical manifestations are similar to those of GABHS pharyngitis, although about half of patients with A haemolyticum pharyngitis develop a rash, which typically starts on the extensor surfaces; spares the palms, soles, and head; and moves centrally to involve the trunk with a maculopapular or scarlatiniform appearance. A haemolyticum exhibits variable susceptibility to penicillin and is identified more easily on human or rabbit blood agar than on sheep agar, the media traditionally used to identify GABHS.
    • Neisseria gonorrhoeae: Infection with this pathogen is associated with oral-genital contact and is often asymptomatic. N gonorrhoeae may be identified using chocolate or Thayer-Martin agar.[20] Nucleic acid amplification tests from throat rinses appear to be a promising alternative.[21] Because of increasing rates of fluoroquinolone resistance, ceftriaxone is now the only recommended option for treatment of pharyngeal gonorrhea.[22] Treatment aimed at Chlamydia trachomatis is also recommended, since co-infection is common.
    • Mycoplasma pneumoniae: This atypical bacterium is increasingly being identified as an etiologic agent of pharyngitis.[23] M pneumoniae pharyngitis may be associated with pulmonary findings.[24]
    • Yersinia species: Both Yersinia enterocolitica and Yersinia pestis may cause disease. Pharyngeal plague has been linked to the consumption of camel meat.[25]
    • Chlamydia trachomatis and Chlamydophila pneumoniae: Both of these organisms are rare causes of pharyngitis.[23, 21]
    • Corynebacterium diphtheriae: Toxigenic strains of this gram-positive bacillus are common causes of croup.[19] Young patients with C diphtheriae pharyngitis often exhibit inspiratory stridor, sternal retraction, and a barking cough. In severe cases, a membrane formation may impair breathing. The incidence of C diphtheriae pharyngitis in developed countries is low because of high immunization rates.
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Contributor Information and Disclosures
Author

Eric S Halsey, MD  Head, Virology Department, Naval Medical Research Center Detachment-Peru (NMRCD-Peru); Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Eric S Halsey, MD is a member of the following medical societies: Armed Forces Infectious Diseases Society, HIV Medicine Association of America, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Kenneth C Earhart, MD  Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3

Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gordon L Woods, MD  Consulting Staff, Department of Internal Medicine, University Medical Center

Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Thank you to Donald Minnich and Dennis Clark for the preparation and photography of the microbiology specimens.

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Picture of Streptococcus pyogenes at 100 X magnification.
Rapid antigen detection test for group A beta-hemolytic streptococci.
Posterior pharynx with petechiae and exudates in a 12-year-old girl. Both the rapid antigen detection test and throat culture were positive for group A beta-hemolytic Streptococcus.
 
 
 
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