Viral Pharyngitis Clinical Presentation

Sore throat is the chief symptom in patients with viral pharyngitis. Patients may have additional symptoms that vary based on the causal pathogen. 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 symptom. 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 and is more prominent in young children than in adults. Hoarseness is sometimes present. Severe pharyngeal pain or odynophagia is 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 (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 the onset of illness. Military personnel tend to be more ill with hoarseness, chest pain, and respiratory distress.

Pharyngitis associated with EBV infectious mononucleosis

EBV infectious mononucleosis is most commonly observed in adolescents and young adults. Sore throat and fatigue are the most common symptoms. Pharyngeal symptoms are usually associated with other features of the disease (eg, fatigue, skin rash, anorexia).

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 symptom 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 symptoms. 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.

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 than those with EBV infectious mononucleosis. Sore throat is less salient, but fever and malaise are prolonged and are more prominent than in EBV infectious mononucleosis.

Pharyngitis caused by HIV

Patients with primary HIV infection (acute retroviral syndrome) develop acute sore throat similar to infectious mononucleosis. Sore throat is usually accompanied by other symptoms. Fever, sweats, malaise, lethargy, myalgias, anorexia, nausea, diarrhea, and skin rash are prominent symptoms.

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 infectious mononucleosis

Examination of the oral cavity and pharynx reveals the characteristic marked enlargement of the tonsils. Half of patients with infectious mononucleosis 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 infectious mononucleosis and streptococcal pharyngitis. However, palatal petechiae associated with infectious mononucleosis 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 one 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. Profound fatigue 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.

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 EBV infectious mononucleosis except for less prominent pharyngeal signs. The pharynx may be mildly erythematous or almost normal in appearance. Splenomegaly is less common and prominent than in EBV infectious mononucleosis.

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.

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 include enterovirus (eg, poliovirus, coxsackievirus, echovirus), RSV, CMV, rotavirus, reovirus, rubella virus, varicella-zoster virus, measles virus, and HIV-1.