A 19-year-old man comes to your office with a complaint of a sore throat. His illness began 3 days ago with a sore throat, followed by persistent fevers of 102°F.
- What are the common diagnostic considerations for patients with acute sore throat?
- What questions are helpful in determining the cause of sore throat?
- How do you assess for the presence of potentially serious causes of sore throat?
Sore throat was the sixth most common reason for seeking outpatient care in 2000, accounting for 2.1% of all ambulatory visits in the United States.1 Although the term “sore throat” is frequently equated with pharyngitis (inflammation of the pharynx), sore throat often results from other causes. Most cases are benign or self-limited, but sore throat may be the presenting symptom for dangerous and potentially life-threatening conditions. The following discussion covers acute sore throat, which is much more common than chronic sore throat.
The general approach to patients with acute sore throat has been to identify and treat cases of group A β-hemolytic streptococcal (GAS) pharyngitis (“strep throat”) in order to prevent acute rheumatic fever (ARF). GAS infections may also cause suppurative sequelae including peritonsillar abscess, severe parapharyngeal infections, or retropharyngeal abscess. Antibiotic treatment of GAS pharyngitis prevents ARF, decreases the transmission of GAS, shortens the illness by 1 to 2 days, and may reduce suppurative complications.2 However, because ARF is so uncommon in the United States, between 3000 and 4000 cases of GAS pharyngitis would need to be treated to prevent a single case.3 Even without antibiotics, most cases of GAS pharyngitis resolve uneventfully after 7 to 10 days. Poststreptococcal glomerulonephritis is a very rare complication of GAS pharyngitis, and antibiotics do not reduce its incidence.3
The classic history for GAS pharyngitis is the sudden onset of sore throat, odynophagia, fever greater than 101°F, abdominal pain, headache, nausea, and vomiting. Cough, rhinorrhea, and diarrhea are usually absent. The classic physical findings include pharyngeal erythema with tonsillar exudates, palatal petechiae, and anterior cervical adenopathy. Unfortunately, there is broad overlap of clinical manifestations between GAS and nonstreptococcal pharyngitis. Although only 5% to 15% of adults with sore throat have a positive GAS culture, 47% to 75% of such patients receive antibiotics.3–5 Thus, the desire to treat GAS infections has led to the overprescribing of antibiotics; the proper exclusion of patients without GAS could lead to significant reductions in inappropriate antibiotic use.
Recent evidence suggests that the traditional approach to acute pharyngitis should incorporate consideration of another infectious agent, Fusobacterium necrophorum. This bacterium is the causative agent for acute pharyngitis in approximately 10% of patients age 15 to 30 years old, which is equivalent to GAS.6 F necrophorum causes Lemierre syndrome (LS), a potentially life-threatening suppurative thrombophlebitis of the internal jugular vein, which may lead to bacteremia and metastatic infections via septic emboli (usually pulmonary abscesses). The mortality of patients with LS ...