Pediatric Pharyngitis Clinical Presentation

  • Author: Harold K Simon, MD, MBA; Chief Editor: Russell W Steele, MD   more...
 
Updated: Apr 24, 2012
 

History

Clinical differentiation of the various pathogens of pharyngitis is difficult based on history or physical examination. In 1962, Feinstein et al noted, "The only typical feature of streptococcal infections is the failure to show a single, consistent, typical feature."

  • History of exposure to known carriers, fever, headache, and abdominal pain in conjunction with sore throat suggest group A beta-hemolytic streptococci (GABHS) pharyngitis. Involvement of other mucous membranes (eg, conjunctivitis, coryza) suggests a viral etiology.
  • Age may also dictate level of concern because GABHS is rarely a true pathogen in children younger than 2 years.
  • Because supportive care is a primary goal in all cases, historical information regarding oral intake and hydration status is important.
  • Obtain information about previous treatments, treatment failures, and medication allergies.
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Physical

Although no single finding or combination of physical findings distinguishes GABHS from a viral etiology, the following items are suggestive:

  • GABHS pharyngitis is often associated with headache, pharyngeal exudate, painful cervical adenopathy, GI symptoms, chills, and high fever.
  • Viral pharyngitis is usually associated with sneezing, rhinorrhea, and cough. For example, H1N1 influenza can present with sore throat but also has other associated symptoms, such as rhinorrhea and/or cough
  • Mononucleosis is typically exudative with extensive false membranes.
  • Herpangina (usually coxsackievirus A) is associated with papulovesicular lesions of the skin (ie, hand-foot-and-mouth disease).
  • Diphtheria, which is rare in developed countries, is associated with a thick gray membrane that is difficult to remove. It is highly friable and bleeds if manipulated.

Any one particular sign or symptom, in addition to sore throat, has low specificity in distinguishing GABHS from viral etiologies. Also look for tonsillar asymmetry, which may be a sign of peritonsillar abscesses. This condition can occur in conjunction with soft palate bulging and deviation of the uvula.

Pay particular attention to signs of dehydration because supportive care is a primary concern and essential regardless of the etiologic agent.

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Causes

Causes include the following:

  • Pharyngitis may be bacterial or viral in origin.
  • Primary bacterial pathogens account for approximately 30% of cases in children.
  • Viruses are isolated in approximately 40% of cases.
  • In nearly 30% of cases, no pathogen is isolated.
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Contributor Information and Disclosures
Author

Harold K Simon, MD, MBA  Professor of Pediatrics and Emergency Medicine, Associate Division Director of Pediatric Emergency Medicine, Director of Research, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston

Harold K Simon, MD, MBA is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Rosemary Johann-Liang, MD  Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

  1. [Guideline] Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2009 Jan. [Full Text].

  2. Fretzayas A, Moustaki M, Kitsiou S, Nychtari G, Nicolaidou P. The clinical pattern of group C streptococcal pharyngitis in children. J Infect Chemother. Aug 2009;15(4):228-32. [Medline].

  3. American Academy of Pediatrics. Report of the committee on infectious diseases. Pickering LK, Baker CJ, McMillan J, Long S (Editors). Red Book. 27th Edition. Elk Grove Village, Il: American Academy of Pediatrics; 2006:430-439.

  4. [Best Evidence] [Guideline] 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].

  5. el-Daher NT, Hijazi SS, Rawashdeh NM, et al. 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].

  6. Wannamaker LW, Rammelkamp CH Jr, 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].

  7. 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].

  8. Chi H, Chiu NC, Li WC, Huang FY. Etiology of acute pharyngitis in children: is antibiotic therapy needed?. J Microbiol Immunol Infect. Mar 2003;36(1):26-30. [Medline].

  9. Denny FW, Wannamaker LW, Brink WR, et al. Landmark article May 13, 1950: Prevention of rheumatic fever. Treatment of the preceding streptococcic infection. JAMA. Jul 26 1985;254(4):534-7. [Medline].

  10. Edress D. Dosing Handbook. 4th ed. Egleston Scottish Rite Children's Healthcare System; 1999-2000.

  11. Feder HM Jr, Gerber MA, Randolph MF, et al. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics. Jan 1999;103(1):47-51. [Medline]. [Full Text].

  12. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].

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  14. Krober MS, Weir MR, Themelis NJ, van Hamont JE. Optimal dosing interval for penicillin treatment of streptococcal pharyngitis. Clin Pediatr (Phila). Nov 1990;29(11):646-8. [Medline].

  15. Marvez-Valls EG, Stuckey A, Ernst AA. A randomized clinical trial of oral versus intramuscular delivery of steroidsin acute exudative pharyngitis. Acad Emerg Med. Jan 2002;9(1):9-14. [Medline].

  16. 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].

  17. Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician. Dec 1990;42(6):1567-76. [Medline].

  18. Roosevelt GE, Kulkarni MS, Shulman ST. Critical evaluation of a CLIA-waived streptococcal antigen detection test inthe emergency department. Ann Emerg Med. Apr 2001;37(4):377-81. [Medline].

  19. Smeesters PR, Campos D, Van Melderen L, et al. Pharyngitis in low-resources settings: a pragmatic clinical approach to reduce unnecessary antibiotic use. Pediatrics. Dec 2006;118(6):e1607-11. [Medline].

  20. Snellman LW, Stang HJ, Stang JM, et al. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics. Jun 1993;91(6):1166-70. [Medline].

  21. 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].

 
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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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