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. The image below shows a posterior pharynx with petechiae and exudates in a 12-year-old girl with group A beta-hemolytic streptococci infection.
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.
Epidemiology
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.
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