Sore Throat

Differential Overview

❑ Rhinovirus

❑ Group A streptococci

❑ Ebstein-Barr virus

❑ Adenovirus

❑ Influenza

❑ Candida/thrush

❑ Herpes simplex virus

❑ Peritonsillar abscess

❑ Mycoplasma pneumoniae

❑ Coxsackievirus

❑ Primary HIV

❑ Neisseria gonorrhea

❑ Epiglottitis

❑ Corynebacterium diphtheriae

❑ Leukemia

Diagnostic Approach

The most important consideration is whether the patient has a group A strep infection because prompt treatment prevents rheumatic fever. The findings of fever, tender anterior cervical adenopathy, and tonsillar exudate can be combined to make the diagnosis more or less likely. Rapid antigen tests have a sensitivity of 80% to 90% and specificity of 95% to 100%, so give a reasonably accurate diagnosis. Because of limitations in sensitivity however, patients with a high suspicion on clinical grounds should have a backup culture taken.

 Prior probability in an adult population with sore throat is 5% to 10%, and in a pediatric population 20% to 25%. A prominent sore throat out of proportion to the degree of pharyngeal inflammation should raise the possibility of acute epiglottitis and acutely impending airway compromise. Persistent unilateral tonsillar enlargement in a young adult without sore throat should raise the suspicion of lymphoma.

Clinical Findings

Rhinovirus  The sore throat is mildly scratchy with nasal congestion, rhinorrhea, and nonproductive cough.

Group A streptococci  There is acute onset of a bright red throat with a tonsillar exudate, fever, and tender anterior cervical adenopathy. Cough and rhinorrhea are usually absent.

Ebstein-Barr virus  Infectious mononucleosis is a systemic illness with fever and prominent fatigue. The tonsils are usually quite large and covered with an exudate. Palatal petechiae, posterior cervical adenopathy, and splenomegaly are helpful clues although not always present. The pharyngitis will persist longer than with other agents.

Adenovirus  Infection causes a febrile pharyngitis and conjunctivitis that occurs in the summer.

Influenza  Sore throat is a relatively minor manifestation compared with fever and myalgias. This occurs in the context of a community outbreak.

Candida/thrush  A cottage cheese-like exudate appears on the throat, tongue, and buccal mucosa with the underlying mucosa becoming bright red. Precipitating factors include immune compromise, such as HIV, diabetes, or use of inhaled steroids for asthma.

Herpes simplex virus  Infection presents as a vesicular and ulcerative pharyngitis/stomatitis. Often a typical vesicular “cold sore” will be present on the lip.

Peritonsillar abscess  Abscess is recognized by the severity of the sore throat, high fever, toxic appearance of the patient, and trismus with drooling (unable to open the mouth or swallow). A unilateral bulging of the anterior tonsillar pillar may be fluctuant and displace the uvula. The patient has a muffled “hot potato” voice. Common carotid infection can lead to rupture, heralded by bleeding in the nose, mouth, or ear.

Mycoplasma pneumoniae  Associated symptoms include a prominent dry cough or a syndrome of atypical pneumonia. Bullous otitis media, when present, is diagnostically helpful.

Coxsackievirus  Vesicles and ulcers on the tonsillar pillars and soft palate appear similar to herpes.

Primary HIV  Sore throat occurs in 70%. Characteristic features include an acute monolike illness with fever, lymphadenopathy, diffuse maculopapular rash including involvement of the palms or soles, and mucocutaneous ulceration. Question about risk factors for HIV transmission.

Neisseria gonorrhea  Many cases are asymptomatic. A history of oral-genital contact can be elicited.

Epiglottitis  The patient has a severe sore throat without erythema, appears acutely anxious, sits forward, and has stridor. The edematous uvula may project over the base of the tongue.

Corynebacterium diphtheriae  An adherent bluish-white to green-gray membrane covers the tonsils and causes bleeding if removed. The patient is severely lethargic often with stridor. There is a “bull’s neck” appearance due to submental and cervical adenopathy. The breath is said to smell like a “wet mouse.”

Leukemia  A nonspecific sore throat, asthenia, lymphadenopathy, and gum infiltrates are indicators.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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