Pharyngitis in Emergency Medicine 

  • Author: John R Acerra, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: May 6, 2010
 

Background

Pharyngitis is defined as an infection or irritation of the pharynx and/or tonsils. The etiology is usually infectious, with most cases being of viral origin. These cases are benign and self-limiting for the most part. Bacterial causes of pharyngitis are also self-limiting, but are concerning because of suppurative and nonsuppurative complications. Other causes include allergy, trauma, toxins, and neoplasia.[1]

The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes); this is shown in the image below.

Streptococcus pyogenes at 100X magnification. Streptococcus pyogenes at 100X magnification.

Physical findings of GAS are shown in the image below.

Posterior pharynx with petechiae and exudates in aPosterior 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 streptococci.

The main ED concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A beta-hemolytic streptococcal (GAS) infections. Airway obstruction is also of utmost importance for the ED physician treating pharyngitis.

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Pathophysiology

With infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response. Other viruses, such as rhinovirus and coronavirus, can cause irritation of pharyngeal mucosa secondary to nasal secretions.[2]

Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases. In addition, M protein fragments of certain serotypes of GAS are similar to myocardial sarcolemma antigens and are linked to rheumatic fever and subsequent heart valve damage. Acute glomerulonephritis may result from antibody-antigen complex deposition in glomeruli.[3]

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Epidemiology

Frequency

United States

Children experience more than 5 upper respiratory infections (URIs) per year and an average of one streptococcal infection every 4 years. The occurrence in adults is about one half that rate. The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes), and the most common viruses are rhinovirus and adenovirus. GAS is most prevalent in late fall through early spring.[1]

International

The incidence of pharyngitis is higher internationally. Antibiotic resistance may be more prevalent in some countries because of overprescription of antibiotics. Note, however, that despite this, there has never been a documented case of GAS resistant to penicillin anywhere in the world.[4]

Mortality/Morbidity

  • In the developing world, an estimated 20 million people are affected by acute rheumatic fever and rheumatic heart disease, making this the leading cause of cardiac death during the first 5 decades of life. This incidence of rheumatic heart disease is dramatically lower in most developed countries, but localized outbreaks have occurred in the Western world. Despite this, new cases of rheumatic heart disease in the United States are extremely rare.[5]
  • Other sequelae of streptococcal pharyngitis include acute glomerulonephritis, peritonsillar abscess, and toxic shock syndrome.
  • Mortality from pharyngitis is rare but may result from one of its complications, most notably airway obstruction.

Age

Pharyngitis occurs with much greater frequency in the pediatric population. Approximately 15-30% of pharyngitis cases among school-aged children in the cooler months are due to GAS. Only 10% of adult cases of pharyngitis are due to GAS.[1]

  • The peak incidence of bacterial and viral pharyngitis occurs in the school-aged child aged 4-7 years.
  • Pharyngitis, especially GAS infection, is rare in children younger than 3 years.
  • Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus are other bacterial causes of pharyngitis, but these pathogens are rare. Antibiotics covering atypical pathogens should not routinely be used to treat pharyngitis.[2]
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Contributor Information and Disclosures
Author

John R Acerra, MD  Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine; Associate Director, International Emergency Medicine Fellowship, North Shore - LIJ Health System

John R Acerra, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  2. Twefik TL, Al Garni M. Tonsillopharyngitis: Clinical highlights. J of Otolaryngology. 2005;34.

  3. Mostov PD. Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Prim Care. Mar 2007;34(1):39-58. [Medline].

  4. Pichichero ME, Casey JR. Systematic review of factors contributing to penicillin treatment failure in Streptococcus pyogenes pharyngitis. Otolaryngol Head Neck Surg. Dec 2007;137(6):851-857. [Medline].

  5. [Guideline] Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51. [Medline].

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  10. Lemierre's syndrome, reemergence of a forgotten disease: a case report. Cases J. Mar 10 2009;2:6397. [Medline].

  11. [Best Evidence] Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics. Feb 2009;123(2):437-44. [Medline].

  12. Ayanruoh S, Waseem M, Quee F, Humphrey A, Reynolds T. Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department. Pediatr Emerg Care. Nov 2009;25(11):748-50. [Medline].

  13. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Emerg Med. Jun 2001;37(6):711-9. [Medline].

  14. Patel NN, Patel DN. Acute exudative tonsillitis. Am J Med. Jan 2009;122(1):18-20. [Medline].

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  16. Tasar A, Yanturali S, Topacoglu H, Ersoy G, Unverir P, Sarikaya S. Clinical efficacy of dexamethasone for acute exudative pharyngitis. J Emerg Med. Nov 2008;35(4):363-7. [Medline].

  17. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. Sep-Oct 2007;5(5):436-43. [Medline].

  18. Van Howe RS, Kusnier LP 2nd. Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes. Pediatrics. Mar 2006;117(3):609-19. [Medline].

  19. Pichichero ME. Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis. Clin Pediatr (Phila). Jul 2006;45(6):493-502. [Medline].

  20. Pichichero M, Casey J. Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis. Eur J Clin Microbiol Infect Dis. Jun 2006;25(6):354-64. [Medline].

  21. Brook I. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Int J Pediatr Otorhinolaryngol. Oct 2007;71(10):1501-8. [Medline].

  22. Depdham D, Rao S, Hitchcock K. Should you treat carriers of pharyngeal group A strep?. J Fam Pract. 2008;57.

  23. [Best Evidence] Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. Jan 21 2009;CD004872. [Medline].

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Streptococcus pyogenes at 100X 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 streptococci.
 
 
 
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