eMedicine Specialties > Infectious Diseases > HEENT Infections

Pharyngitis, Viral

KoKo Aung, MD, MPH, FACP, Associate Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health
Ambrish Ojha, MD, Staff Physician, Department of Internal Medicine, Texas Tech University Health Sciences Center; Carson Lo, MD, Staff Physician, Department of Medicine, Memorial Hermann Southwest Hospital

Updated: Jan 20, 2009

Introduction

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.

Most cases are caused by viruses and occur as part of common colds and influenzal syndromes. For information on bacterial pharyngitis, see the eMedicine article Pharyngitis, Bacterial in the Infectious Diseases volume.

Pathophysiology

Several viruses can cause viral pharyngitis.

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.

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.

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 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 the eMedicine article Pharyngitis in the Pediatrics: General Medicine volume.

Clinical

History

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.

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 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.

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

Differential Diagnoses

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

Laboratory 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/µL after 4-7 days of illness in about 50% of cases.
• Atypical lymphocytosis is frequently associated with EBV and CMV infections.
• Results from a rapid streptococcal antigen test and a bacterial culture of throat swab in viral pharyngitis may be positive (approximately 30% of patients with EBV infectious mononucleosis are colonized with group A streptococci).
• 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.
• EBV infectious mononucleosis: After week one of illness, 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. Erythrocyte sedimentation rate (ESR) is elevated and liver function test results are mildly 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 infectious mononucleosis 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 infectious mononucleosis. Heterophile test results are usually negative (heterophile-negative mononucleosis syndrome).

Treatment

Medical Care

Treatment strategies for patients with acute pharyngitis are based on epidemiologic factors, signs and symptoms, and results of laboratory tests.¹ Rest, oral fluids, and salt-water gargling (for soothing effect) are the main supportive measures in patients with viral pharyngitis.²

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. Aspirin should not be used in children or adolescents, especially with influenza, because of its association with Reye syndrome. One study proved that ibuprofen was superior to acetaminophen for symptomatic relief in children aged 6-12 years. A double-blind randomized study involving adult patients from 27 study centers in Latin America found that 5 days of treatment with celecoxib 200 mg once daily is as effective as diclofenac 75 mg twice daily in the symptomatic treatment of viral pharyngitis.³

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. The risks of prescribing antibiotics in patients with viral pharyngitis include the common side effects of antibiotics (diarrhea, rashes, candidiasis, unplanned pregnancy secondary to oral-contraceptive failure) and the rare occurrence of anaphylaxis.⁴

Specific treatment of viral infections is available for only a few viruses.

• Influenza
  • Beginning treatment with one of the adamantanes (amantadine or rimantadine) within 48 hours of the onset of illness decreases the duration of symptoms in influenza A infection.⁵ However, both agents lack activity against influenza B infection, which is usually mild.
  • Adamantanes can be used in 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.
  • Ribavirin has helped patients severely ill with influenza A or B infections.
  • Newer neuraminidase inhibitors (inhaled zanamivir, oral oseltamivir) started within 30 hours of the onset of influenza can shorten the duration of symptoms and, possibly, decrease the rate of complications.⁶
  • Drug resistance of different strains of influenza A and B complicates antiviral therapy. Of the 50 influenza A (H1N1) viruses identified in the United States from October 1, 2008, through December 13, 2008, and tested by the CDC, 49 (98%) were resistant to oseltamivir. All influenza A (H1N1) viruses tested in fall 2008 were susceptible to the adamantanes (amantadine and rimantadine). All influenza A (H3N2) and influenza B viruses tested in fall 2008 were susceptible to oseltamivir, and all influenza A (H1N1) and A (H3N2) and influenza B viruses tested during this period were susceptible to zanamivir. Resistance to the adamantanes among influenza A (H3N2) viruses remained high at the time of this revision (December 25, 2008), with 100% of viruses tested found to be adamantane-resistant.⁷
• EBV 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 infectious mononucleosis is usually benign and self-limited.
  • However, corticosteroids are indicated if the patient has massive 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

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

Analgesics/antipyretics

These agents are often helpful in relieving the pain and fever associated with pharyngitis.

Acetaminophen (Tylenol)

Relieves pain by elevation of the pain threshold. Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.

Dosing

Adult

325-650 mg PO q4-6h prn; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: Administer as in adults

Interactions

Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose

Ibuprofen (Advil, Motrin)

Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 5-10 mg/kg/dose PO q4-6h prn; not to exceed 40 mg/kg/d
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity (animal studies only); phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity to ibuprofen or other NSAIDs

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Risk of GI ulceration, bleeding, and perforation, particularly in patients with active peptic ulcer disease or with a history of peptic ulcer disease; caution in CHF, hypertension, and decreased renal function (maintenance of renal perfusion highly dependent on renal prostaglandins) and hepatic function (severe hepatic reactions including jaundice and cases of fatal hepatitis have been reported); caution in anticoagulation abnormalities or during anticoagulant therapy (inhibits platelet aggregation); if signs or symptoms of meningitis develop, the possibility of aseptic meningitis related to ibuprofen should be considered; if blurred and/or diminished vision, scotomata, and/or changes in color vision develop, ibuprofen should be discontinued, and visual field and color vision testing should be performed; not recommended in breastfeeding mothers

Topical anesthetics

These agents soothe irritated or inflamed mucous membranes associated with sore throat.

Benzocaine (Trocaine, Benzocol, Cylex, Cepacol Maximum Strength)

Lozenges or gargle reduces pain associated with pharyngitis. Inhibits neuronal membrane depolarization, blocking nerve impulses.

Dosing

Adult

Dissolve 1 lozenge (10 mg) in mouth q2h prn

Pediatric

<6 years: Not established
>6 years: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Reevaluate the patient if sore throat is severe, persists for more than 2 d, or is accompanied or followed by fever, headache, rash, nausea, or vomiting

Antiviral Agents

These agents are used specifically to treat viral infections. They are available for only a few viruses.

Amantadine (Symmetrel)

Active against influenza A virus. Has little or no activity against influenza B virus isolates. Mechanism of antiviral action is unclear. Prevents release of infectious viral nucleic acid into the host cell by interfering with the function of the transmembrane domain of the viral M2 protein. In certain cases, known to prevent virus assembly during virus replication. Treatment begun within 48 h of the onset of symptoms decreases the duration of fever and other symptoms.

Dosing

Adult

200 mg/d PO qd or divided bid; split dosage schedule may reduce adverse CNS effects
>65 years: 100 mg/d PO qd or divided bid
Hemodialysis: 200 mg PO qwk

Pediatric

<1 year: Not recommended
1-9 years: 4.4-8.8 mg/kg/d PO qd or divided bid; not to exceed 150 mg/d
9-12 years: 100 mg PO bid
>12 years: Administer as in adults

Interactions

Agents with anticholinergic activity potentiate anticholinergic adverse effects; concurrent administration of triamterene/ hydrochlorothiazide may increase plasma concentrations; coadministration of thioridazine has been reported to worsen tremor in elderly patients with Parkinson disease; however, it is not known if other phenothiazines produce similar response; trimethoprim/ sulfamethoxazole may impair renal clearance, resulting in higher plasma concentrations; coadministration of quinine or quinidine decreases renal clearance

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in liver disease, uncontrolled psychosis, eczematoid dermatitis, seizures, and those receiving CNS stimulant drugs; reduce dose in renal dysfunction; do not discontinue this medication abruptly

Rimantadine (Flumadine)

Inhibits viral replication of influenza A virus H1N1, H2N2, and H3N2 with little or no activity against influenza B virus. Prevents penetration of the virus into the host by inhibiting uncoating of influenza A. Does not appear to interfere with the immunogenicity of inactivated influenza A vaccine. Can be used together during an outbreak.

Dosing

Adult

100 mg PO bid
CrCl <10 mL/min, severe hepatic dysfunction, and elderly nursing home patients: 100 mg PO qd

Pediatric

<10 years: Not recommended
>10 years: Administer as in adults

Interactions

Acetaminophen and aspirin reduce levels when taken concurrently; cimetidine increases plasma levels when taken concomitantly

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment; should be discontinued if seizures develop

Oseltamivir (Tamiflu)

Inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, decreases release of viruses from infected cells and thus viral spread. Effective to treat influenza A or B. Start within 40 h of symptom onset. Available as capsules and an oral suspension.

Dosing

Adult

Acute illness: 75 mg PO bid for 5 d
Prophylaxis: 75 mg PO qd for 10 d

Pediatric

Acute illness:
<1 year: Not indicated
>1 year:
<15 kg: 30 mg PO bid for 5 d
>15-23 kg: 45 mg PO bid for 5 d
>23-40 kg: 60 mg PO bid for 5 d
>40 kg: Administer as in adults

Prophylaxis:
<1 year: Not established
>1 year:
<15 kg: 30 mg PO qd for 10 d
>15-23 kg: 45 mg PO qd for 10 d
24-40 kg: 60 mg PO qd for 10 d
>40 kg: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal impairment, chronic cardiac or respiratory disease, and breastfeeding; do not use in children <1 y (preclinical trials have demonstrated death in young animals, possibly related to immature blood-brain barriers); postmarketing reports (mostly from Japan) of self-injury and delirium in patients with influenza (reports primarily among children), unknown if oseltamivir directly contributes to this behavior (monitor for abnormal behavior throughout treatment period)

Acyclovir (Zovirax)

Synthetic purine nucleoside analogue with in vitro and in vivo inhibitory activity against HSV-1, HSV-2, and VSV. Inhibitory activity is highly selective because of its affinity for the enzyme thymidine kinase (TK) encoded by HSV and VZV.

Dosing

Adult

Acute herpetic pharyngitis or gingivostomatitis: 200 mg PO 5 times/d or 400 mg PO tid for 10-14 d

Pediatric

<2 years: Not recommended
>2 years: 20 mg/kg/dose PO qid for 10-14 d; not to exceed 800 mg/d

Interactions

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity; decreases the renal clearance of methotrexate with potential toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure (adjust dose) or when using nephrotoxic drugs; caution in breastfeeding mothers

Valacyclovir (Valtrex)

Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.

Dosing

Adult

500-1000 mg PO bid

Pediatric

Not established

Interactions

Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome

Famciclovir (Famvir)

Prodrug that when biotransformed into active metabolite, penciclovir, may inhibit viral DNA synthesis/replication.

Dosing

Adult

250-500 mg PO tid

Pediatric

Not recommended

Interactions

Coadministration of probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure or coadministration of nephrotoxic drugs

Antiviral Agent, Inhalation Therapy

Zanamivir (Relenza)

Inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Effective against both influenza A and B. To be inhaled through Diskhaler oral inhalation device. Circular foil discs containing 5-mg blisters of drug are inserted into supplied inhalation device.

Dosing

Adult

Treatment: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO q12h for 5 d; initiate within 2 d of symptom onset
Prophylaxis: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO qd for 10 d; initiate within 36 h of exposure

Pediatric

Treatment:
<7 years: Not established
>7 years: Administer as in adults

Prophylaxis:
<5 years: Not established
>5 years: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity, obstructive airway disease

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor respiratory status; may cause bronchospasm; caution in breastfeeding

Follow-up

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.
• Infectious mononucleosis 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. For more information, see the eMedicine article HIV Disease.

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 infectious mononucleosis, 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. It is often challenging to reassure that antibiotic therapy is unnecessary.²
• 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

Medicolegal 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.
• A systematic review that examined the precision and accuracy of the clinical examination in diagnosing streptococcal pharyngitis found that the most useful findings for evaluating the likelihood of streptococcal pharyngitis included the presence of tonsillar exudate, pharyngeal exudate, or exposure to strep throat infection in the previous 2 weeks (positive likelihood ratios, 3.4, 2.1, and 1.9, respectively) and the absence of tender anterior cervical nodes, tonsillar enlargement, or exudate (negative likelihood ratios, 0.60, 0.63, and 0.74, respectively).⁸
• 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.
• Unnecessary antibiotic therapy for viral pharyngitis can lead to medicalization of a self-limiting illness, resulting in increasing reattendance for future episodes of this condition.⁹
• 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.¹⁰ 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.¹¹ 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

1. Perkins A. An approach to diagnosing the acute sore throat. Am Fam Physician. Jan 1997;55(1):131-8, 141-2. [Medline].

2. Bisno AL. Acute pharyngitis. N Engl J Med. Jan 18 2001;344(3):205-11. [Medline].

3. Weckx LL, Ruiz JE, Duperly J, et al. Efficacy of celecoxib in treating symptoms of viral pharyngitis: a double-blind, randomized study of celecoxib versus diclofenac. J Int Med Res. Mar-Apr 2002;30(2):185-94. [Medline].

4. Graham A, Fahey T. Evidence based case report. Sore throat: diagnostic and therapeutic dilemmas. BMJ. Jul 17 1999;319(7203):173-4. [Medline].

5. Rimantadine for prevention and treatment of influenza. Med Lett Drugs Ther. Nov 26 1993;35(910):109-10. [Medline].

6. Two neuraminidase inhibitors for treatment of influenza. Med Lett Drugs Ther. Oct 8 1999;41(1063):91-3. [Medline].

7. Additional Considerations to the Interim Recommendations for the Use of Influenza Antiviral Medications in the Setting of Oseltamivir Resistance among Circulating Influenza A (H1N1) Viruses, 2008-09 Influenza Season. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/flu/professionals/antivirals/additional_considerations.htm. Accessed 12/25/2008.

8. Ebell MH, Smith MA, Barry HC, et al. The rational clinical examination. Does this patient have strep throat?. JAMA. Dec 13 2000;284(22):2912-8. [Medline].

9. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL. Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ. Aug 9 1997;315(7104):350-2. [Medline].

10. McIsaac WJ, White D, Tannenbaum D, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. Jan 13 1998;158(1):75-83. [Medline].

11. Singh S, Dolan JG, Centor RM. Optimal management of adults with pharyngitis--a multi-criteria decision analysis. BMC Med Inform Decis Mak. Mar 13 2006;6:14. [Medline].

12. Cunha BA. Group A streptococcal pharyngitis. Emerg Med. 1990;22:93-96.

13. Cunha BA. Group A streptococcal pharyngitis versus colonization. Intern Med. 1994;15:18-19.

14. Cunha BA. The Sore Throat: Mycoplasma pneumoniae pharyngitis. Emerg Med. 1988;20:245-252.

15. Gwaltney JM Jr, Bisno AL. Pharyngitis. In: Mandell GI, Bennett JE, Dolin R, eds. Mandell, Douglas & Bennett's Principles of Infectious Diseases. Vol 1. Churchill Livingstone; 2000:656-62.

16. Huovinen P, Lahtonen R, Ziegler T, et al. Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med. Apr 15 1989;110(8):612-6. [Medline].

17. McIsaac WJ, Goel V, Slaughter PM. Reconsidering sore throats. Part 2: Alternative approach and practical office tool. Can Fam Physician. Mar 1997;43:495-500. [Medline].

18. McIsaac WJ, Goel V, Slaughter PM, et al. Reconsidering sore throats. Part I: Problems with current clinical practice. Can Fam Physician. Mar 1997;43:485-93. [Medline].

19. Paradise JL. Etiology and management of pharyngitis and pharyngotonsillitis in children: a current review. Ann Otol Rhinol Laryngol Suppl. Jan 1992;155:51-7. [Medline].

20. Pichichero ME. Sore throat after sore throat after sore throat. Are you asking the critical questions?. Postgrad Med. Jan 1997;101(1):205-6, 209-12, 215-8, passim. [Medline].

21. Wolter JM. Management of a sore throat. Antibiotics are no longer appropriate. Aust Fam Physician. Apr 1998;27(4):279-81. [Medline].

22. Yoda K, Sata T, Kurata T, et al. Oropharyngotonsillitis associated with nonprimary Epstein-Barr virus infection. Arch Otolaryngol Head Neck Surg. Feb 2000;126(2):185-93. [Medline].

Keywords

viral pharyngitis, sore throat, acute pharyngitis, rhinoviral pharyngitis, adenoviral pharyngitis, EBV pharyngitis, HSV pharyngitis, influenzal pharyngitis, parainfluenzal pharyngitis, coronaviral pharyngitis, enteroviral pharyngitis, echoviral pharyngitis, RSV pharyngitis, CMV pharyngitis, cytomegaloviral pharyngitis, common cold, flu, influenza, pharynx, tonsils, upper respiratory tract infection, URTI, rhinovirus, adenovirus, Epstein-Barr virus, EBV, herpes simplex virus, HSV, parainfluenza virus, coronavirus, enterovirus, respiratory syncytial virus, RSV, cytomegalovirus, CMV, human immunodeficiency virus, HIV, coxsackievirus, echovirus, acute retroviral syndrome, infectious mononucleosis, IM, group A beta hemolytic streptococcus, GABHS

Contributor Information and Disclosures

Author

KoKo Aung, MD, MPH, FACP, Associate Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health
KoKo Aung, MD, MPH, FACP is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Ambrish Ojha, MD, Staff Physician, Department of Internal Medicine, Texas Tech University Health Sciences Center
Ambrish Ojha, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Carson Lo, MD, Staff Physician, Department of Medicine, Memorial Hermann Southwest Hospital
Carson Lo, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Gregory William Rutecki, MD, Associate Professor, Program Director, Department of Internal Medicine, Feinberg School of Medicine, Northwestern University
Gregory William Rutecki, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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.

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