Pediatric Pharyngitis

Updated: Apr 26, 2016
  • Author: Harold K Simon, MD, MBA; Chief Editor: Russell W Steele, MD  more...
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Overview

Background

Pharyngitis is a leading cause of pediatric ambulatory care visits. Examination of patients who present with sore throat may reveal tonsillitis, tonsillopharyngitis, or nasopharyngitis. [1] The absence of pharyngeal inflammation or the presence of rhinorrhea is much more likely to be associated with viral infection. However, no physical findings clearly separate group A beta-hemolytic streptococci (GABHS) from viral, other bacterial, or noninfectious causes.

The primary concern for pharyngitis in children aged 2 years or older is that untreated GABHS pharyngitis may subsequently cause rheumatic fever. To prevent this sequela, institute adequate antimicrobial therapy within 9 days of infection. Rapid antigen detection assays for GABHS are diagnostic if positive because the specificity of such tests is 98-99% (ie, 1-2% false-positive results); however, their sensitivity is only 70% (ie, 30% false-negative results), necessitating follow-up cultures for negative results.

The drug of choice for treatment of GABHS pharyngitis remains penicillin V, although many experts recommend a higher dosage than was used in the past. Other bacteria that occasionally cause pharyngitis and require antimicrobial therapy include gonococcus; Francisella tularensis; groups B, C, [2] and G streptococci; Arcanobacterium hemolyticum; and Treponema pallidum. No treatment is of any benefit for the usual viral causes of pharyngitis.

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Pathophysiology and Etiology

Multiple entities can cause irritation and inflammation of the pharynx. In children, such causes range from viruses (eg, adenoviruses, enteroviruses, and Epstein-Barr virus [EBV]), which often require only supportive therapy, to bacterial pathogens (eg, GABHS), which require antibiotic therapy. For all cases of pediatric pharyngitis, whether of bacterial or viral origin, supportive care is necessary to prevent associated symptoms such as dehydration.

Primary bacterial pathogens account for approximately 30% of cases of pharyngitis in children. These include the following:

  • GABHS (common)
  • Arcanobacterium hemolyticum (7% of adolescents and adults with pharyngitis)
  • Group C streptococci (uncommon)
  • Group G streptococci (uncommon)
  • Neisseria gonorrhoeae (uncommon)
  • Corynebacterium diphtheriae (rare)

No pathogen is isolated in nearly 30% of cases, and viruses are isolated in approximately 40% of cases. Other probable copathogens in children include the following:

GABHS is the primary organism of concern in most pediatric cases of pharyngitis because appropriate antibiotic therapy is effective and can eliminate the cardiac complications of rheumatic fever. More than 80 M-protein types of GABHS have been isolated. Serotypes 1, 3, 5, 6, 18, 19, and 24 are associated with rheumatic fever (and thus are referred to as rheumatogenic forms), whereas others, such as serotypes 49, 55, and 57, are associated with pyoderma and acute poststreptococcal glomerulonephritis.

GABHS pharyngitis is spread via respiratory droplets through close contact. It has an incubation period of 2-5 days.

A study found that in adolescents and young adults, Fusobacterium necrophorum pharyngitis was more common than group A beta-hemolytic streptococcal (GAS) pharyngitis. European data suggest that in patients aged 15 to 30 years, Fusobacterium necrophorum causes at least 10% of cases of pharyngitis. The study also observed that F. necrophorum was the primary cause of Lemierre syndrome in this age group. [3, 4]

Viruses that may cause acute viral pharyngitis include the following:

  • EBV (mononucleosis) - Produces a shaggy white membrane
  • Rhinovirus
  • Adenovirus
  • Parainfluenza virus
  • Coxsackievirus
  • Coronavirus
  • Echovirus
  • Cytomegalovirus (CMV)

Causes of chronic pharyngitis (usually noninfectious) include the following:

  • Irritation from postnasal discharge of chronic allergic rhinitis
  • Chemical irritation
  • Neoplasms and vasculitides
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Epidemiology

United States statistics

Approximately 10% of children seen by medical care providers each year have pharyngitis, and 25-50% of these children have GABHS pharyngitis. Approximately 20% of asymptomatic children are chronic carriers of GABHS.

International statistics

The entire range of pharyngitis-causing pathogens is observed throughout the world. Certain pathogens that are virtually nonexistent in the United States cause pharyngitis in other areas. A good example is diphtheria, which has been nearly eradicated in the United States through immunizations. According to the Red Book, from 1990-1995, approximately 48,000 cases of epidemic diphtheria were reported in the former Soviet Union and central Asia. [5]

Given the high case-fatality rate of 3-23% and the increased geographic mobility of people, the potential for worldwide spread of diphtheria is a cause for concern. Consider rare or unsuspected causative agents in afflicted individuals who have traveled to high-risk areas or in individuals who have emigrated from these regions, especially if they have not been immunized.

Age-, sex, and race-related demographics

Pharyngitis occurs in all age groups. The peak prevalence of GABHS pharyngitis is in children aged 5-10 years. In children younger than 2 years, most pharyngitis is of viral origin, although GABHS is responsible in rare instances. Viral pharyngitis occurs in persons of all ages. No sex predilection exists. Prevalence is equal among all races.

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Prognosis

For all types of pharyngitis, the prognosis is excellent. Streptococcal pharyngitis has a 5- to 7-day course, and symptoms usually resolve spontaneously, without treatment—though in rare cases, rheumatic fever can develop if GABHS is left untreated. Rarely, peritonsillar abscesses or other local complications develop; these may call for surgical intervention. With supportive care to prevent dehydration and pain, pharyngitis, for the most part, is a self-limiting disease.

Although the prevention of rheumatic fever is the primary reason for treating GABHS, the following interesting observations were made during outbreaks of rheumatic fever in 1985 and 1990:

  • No previous significant increases in GABHS were noted in the communities before the outbreaks; the outbreaks were observed in middle-class areas, where compliance rates with medical therapy are relatively high
  • In these outbreaks, unlike most previous outbreaks, severe pharyngitis was rarely noted; only 46% of patients reported even having a recent sore throat, and only 24% had sore throats serious enough to cause them to seek medical care; in addition, almost 20% of cases were in children who received antibiotics for pharyngitis (antibiotic type, length of therapy, and compliance issues were not recorded)

Therefore, outbreaks may, in fact, be most related to the “rheumatogenicity” of the GABHS.

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Patient Education

Emphasize the importance of the patient’s completing a full course of antibiotics, regardless of symptom response. Instruct families to encourage adequate hydration and to use antipyretics for pain and fever. In addition, instruct parents to seek immediate medical care or consult their primary medical provider if signs of dehydration occur or symptoms worsen.

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