eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Pharyngitis
Updated: Oct 21, 2009
Introduction
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 either rhinorrhea or laryngitis 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.
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.
The primary concern for pharyngitis in children aged 3-18 years is that untreated GABHS 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, sensitivity is only 70% (ie, 30% false-negative results), requiring follow-up cultures for negative results.
The drug of choice to treat group A streptococci 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. Discourage the use of throat lozenges, sprays, mouthwashes, decongestants, and antihistamines.
Pathophysiology
Multiple etiologies can cause irritation and inflammation of the pharynx. Causes in children range from viruses (eg, adenoviruses, enteroviruses, Epstein-Barr virus [EBV]), which often require only supportive therapy, to bacterial pathogens (eg, GABHS), which require antibiotic therapy. GABHS pharyngitis is spread via respiratory droplets through close contact.
No pathogen is isolated in nearly 30% of cases, and viruses are isolated in approximately 40% of cases. Other probable copathogens in children include Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis, Bacteroides melaninogenicus, Fusobacterium species, and Peptostreptococcus species. Less common causes include Chlamydia trachomatis and Mycoplasma pneumoniae.
GABHS is the primary organism of concern in most pediatric cases of pharyngitis because appropriate antibiotic therapy is effective and can eliminate complications of rheumatic heart disease. For all cases, including viral etiologies, supportive care is necessary to prevent associated symptoms such as dehydration.
Frequency
United States
Approximately 10% of children seen by medical care providers each year have pharyngitis, and 25-50% of these children have GABHS. Approximately 20% of asymptomatic children are chronic carriers of GABHS.
International
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.3 Given the high case-fatality rate of 3-23% and the increased 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 for individuals who have emigrated from these regions, especially in nonimmunized patients.
Race
Prevalence is equal among all races.
Age
Peak prevalence of GABHS pharyngitis is in children aged 5-10 years. In children younger than 2 years, most pharyngitis is of viral etiology, although GABHS is responsible in rare instances. Viral pharyngitis occurs in persons of all ages.
Clinical
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.
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.
Causes
- 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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References
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Further Reading
Keywords
pharyngitis, sore throat, tonsillitis, tonsillopharyngitis, nasopharyngitis, pharyngeal inflammation, group A beta-hemolytic streptococci, GABHS, GABHS pharyngitis, viral pharyngitis, rheumatic fever, rhinorrhea, laryngitis, adenoviruses, enteroviruses, treatment, diagnosis
