Introduction
Background
Studies in the late 1940s and 1950s showed that penicillin (PCN) therapy for group A beta-hemolytic streptococcal (GABHS) pharyngitis could prevent rheumatic heart disease. The American Heart Association has recommended PCN therapy since 1953, and this remains the primary treatment of choice to prevent rheumatic heart disease.
Initial studies using a 5- to 7-day course showed a decline in the number of GABHS positive follow-up throat cultures from 53% to 18%. Subsequent 10-day courses of penicillin proved to be the most beneficial in eradicating GABHS from the pharynx. Therefore, the diagnosis and proper treatment of GABHS are of vital importance.
The effectiveness of antimicrobial therapy in the preventing poststreptococcal glomerulonephritis is less certain.
Pathophysiology
GABHS pharyngitis is spread via respiratory secretions through close contacts. It has an incubation period of 2-5 days.
Over 80 M-protein types of GABHS have been isolated with serotypes 1, 3, 5, 6, 18, 19, and 24 associated with rheumatic fever (ie, rheumatogenic forms) and others, such as serotypes 49, 55, and 57, associated with pyoderma and acute poststreptococcal glomerulonephritis.
Causes of pharyngitis in children vary from viruses, which often require only supportive therapy, to bacterial pathogens, such as GABHS, which require antibiotics. Primary bacterial pathogens that account for approximately 30% of cases of pharyngitis in children include GABHS (common), group C streptococci (uncommon), group G streptococci (uncommon), Neisseria gonorrhoeae (uncommon), Corynebacterium diphtheriae (rare), and Corynebacterium hemolyticum (extremely rare).
Viruses are isolated in approximately 40% of cases and include rhinovirus, adenovirus, parainfluenza virus, coxsackievirus, coronavirus, echovirus, herpes simplex virus, Epstein-Barr virus (mononucleosis), and cytomegalovirus.
Other probable copathogens for pharyngitis in children include Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis, Bacteroides melaninogenicus, Fusobacterium species, and Peptostreptococcus species.
Other, less common, causes of pharyngitis include Chlamydia trachomatis and Mycoplasma pneumoniae.
In approximately 30% of cases, no pathogen is isolated.
Frequency
United States
Approximately 10% of children evaluated by medical care providers each year are evaluated for pharyngitis, and 25-50% of them have GABHS. However, it is important to note that approximately 20% of asymptomatic children are long-term carriers of GABHS.
Sex
No sex predilection exists.
Age
- Pharyngitis occurs in all age groups.
- Streptococcal infections have the greatest incidence in those aged 5-18 years.
- In children younger than 2 years, most pharyngitis is of viral etiology, although GABHS rarely can occur in this younger age group.
Clinical
History
- The clinical differentiation of the possible pathogens of pharyngitis often is difficult based on history or physical examination. In 1962, Feinstein et al wrote, "The only typical feature of streptococcal infections is their failure to show a single, consistent, typical feature."
- History of exposure to known carriers
- Fever
- Sore throat
- Headache
- Abdominal pain
- Anorexia
- Chills
- Malaise
Physical
While no single or combination of physical findings is specific for distinguishing GABHS from viral etiologies, several items on physical examination are suggestive.
- Enlarged tonsils
- Pharyngeal erythema
- Tonsillar exudates with necrotic crypts
- Soft-palate petechiae
- Tender cervical adenopathy
- Fever
- Scarlet fever rash (punctate erythematous macules and fine papules with reddened flexor creases and circumoral pallor), the so-called sandpaper rash
- Conjunctivitis (more commonly with adenovirus infections)
- Viral pharyngitis usually is associated with sneezing, rhinorrhea, and cough.
- Mononucleosis typically is exudative with extensive false membranes.
- Herpangina (usually coxsackievirus A) is associated with papulovesicular lesions.
- Diphtheria, which is rare in developed countries, is associated with a thick gray membrane that is difficult to remove.
Causes
- Acute bacterial pharyngitis
- Group A beta-hemolytic streptococci
- N gonorrhoeae
- C diphtheriae
- H influenzae
- Moraxella (Branhamella) catarrhalis
- Group C and G streptococci (rare)
- Acute viral pharyngitis
- Rhinovirus
- Adenovirus
- Parainfluenza virus
- Coxsackievirus
- Coronavirus
- Echovirus
- Epstein-Barr virus (mononucleosis)
- Cytomegalovirus
- Chronic pharyngitis (usually noninfectious)
- Irritation from postnasal discharge of chronic allergic rhinitis
- Chemical irritation
- Neoplasms and vasculitides
More on Pediatrics, Pharyngitis |
 Overview: Pediatrics, Pharyngitis |
| Differential Diagnoses & Workup: Pediatrics, Pharyngitis |
| Treatment & Medication: Pediatrics, Pharyngitis |
| Follow-up: Pediatrics, Pharyngitis |
| References |
| Next Page » |
References
Bulloch B, Kabani A, Tenenbein M. Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med. May 2003;41(5):601-8. [Medline].
Krober MS, Weir MR, Themelis NJ, et al. Optimal dosing interval for penicillin treatment of streptococcal pharyngitis. Clin Pediatr (Phila). Nov 1990;29(11):646-8. [Medline].
American Academy of Pediatrics. Report of the committee on infectious diseases. In: Peter G, ed. Red Book. Elk Grove Village, AAP; & 1997 1994:430-9; 483-9.
Denny FW, Wannamaker LW, Brink WR, et al. Prevention of rheumatic fever; treatment of the preceding streptococcic infection. J Am Med Assoc. May 13 1950;143(2):151-3. [Medline].
el-Daher NT, Hijazi SS, Rawashdeh NM. Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J. Feb 1991;10(2):126-30. [Medline].
Feder HM Jr, Gerber MA, Randolph MF. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics. Jan 1999;103(1):47-51. [Medline].
Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].
Gerber MA, Markowitz M. Streptococcal pharyngitis: Clearing up the controversies. Contemp Pediatr. 1992;118-31.
Marvez-Valls EG, Stuckey A, Ernst AA. A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis. Acad Emerg Med. Jan 2002;9(1):9-14. [Medline].
Peter G, Smith AL. Group A streptococcal infections of the skin and pharynx (second of two parts). N Engl J Med. Aug 18 1977;297(7):365-70. [Medline].
Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician. Dec 1990;42(6):1567-76. [Medline].
Roosevelt GE, Kulkarni MS, Shulman ST. Critical evaluation of a CLIA-waived streptococcal antigen detection test in the emergency department. Ann Emerg Med. Apr 2001;37(4):377-81. [Medline].
Snellman LW, Stang HJ, Stang JM. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics. Jun 1993;91(6):1166-70. [Medline].
Van Cauwenberge PB, Vander Mijnsbrugge A. Pharyngitis: a survey of the microbiologic etiology. Pediatr Infect Dis J. Oct 1991;10(10 Suppl):S39-42. [Medline].
Wannamaker LW, Rammelkamp CH, Denny FW, et al. Prophylaxis of acute rheumatic fever by treatment of the preceding streptococcal infection with various amounts of depot penicillin. Am J Med. Jun 1951;10(6):673-95. [Medline].
Further Reading
Keywords
pharyngitis in children, pharyngitis, group A beta-hemolytic streptococcal pharyngitis, GABHS, group C streptococci, group G streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Corynebacterium hemolyticum, rhinovirus, adenovirus, parainfluenza virus, coxsackievirus, coronavirus, echovirus, herpes simplex virus, Epstein-Barr virus, mononucleosis, cytomegalovirus, Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis, Bacteroides melaninogenicus,Fusobacterium species, Peptostreptococcus species, Chlamydia trachomatis, Mycoplasma pneumoniae
