see also:

• EBV / glandular fever / infectious mononucleosis

• most cases of inflamed tonsils and pharyngitis even with purulent exudate are viral and are often difficult to distinguish clinically from Group A Streptococcal infections
• Streptococcal infections are more common in those aged 3yrs to 13yrs and less so in older children and adults
• In children under 3 yrs, the far majority of throat infections are viral.
• throat swabs are generally of little utility if gonococcal disease is very unlikely as many have Streptococci in the pharynx without it being causative
• When assessing patients with a sore throat, you need to exclude peritonsillar abscess (quinsy) and EBV / glandular fever / infectious mononucleosis and also some important rare but potentially lethal conditions such as:
  • retropharyngeal abscess
    • this is suggested by presence of stridor or a stiff neck (refusal to flex the neck)
  • epiglottitis - now very rare in vaccinated children which has eradicated invasive HiB disease
    • this is suggested by unvaccinated children with stridor and minimal cough
    • if you suspect this in a child, Do NOT examine the throat as this risks sudden airway obstruction
  • scarlet fever
    • this is suggested by features such as a classic scarlatiform rash, strawberry tongue and palatial petechiae
  • Ludwig's angina
    • usually in older adults and presents with swelling to the floor of the mouth
  • diphtheria now exceedingly rare as most are vaccinated
• other differentials to consider:
  • gonococcus - becoming more prevalent in young adults, especially men who have sex with men
  • candida fungal infection / thrush - especially in young children, or in immunocompromised adults
  • some specific viral causes of pharyngitis:
    • herpangina - ulcers on the soft palate
    • Herpes simplex virus (HSV) gingivostomatitis - ulcers in anterior half of mouth and tongue
    • aphthous mouth ulcers
    • hand, foot and mouth disease - may have purplish vesicles on hands and feet, and in infants, a m/p rash on buttocks
    • fifth disease / slapped cheek syndrome / eythema infectiosum - slapped cheek appearance +/- mottly web-like rash to medial aspect upper arms and is caused by Parvovirus B19 which can be an issue for pregnant women

• examine specifically for:
  • evidence of EBV / glandular fever / infectious mononucleosis - posterior cervical LNs, hepatomegaly, splenomegaly
  • evidence of peritonsillar abscess (quinsy)
• FBE, U&Es, CRP, LFTs, IM screen
• if suspected quinsy, admit and discuss with ENT as may need aspiration
• if suspected glandular fever, then see EBV / glandular fever / infectious mononucleosis
• otherwise:
  • admit to ED observation unit if either:
    • significant dysphagia
    • unable to tolerate oral antibiotics
    • dehydrated
    • failed oral antibiotics and unwell
    • potential airway risk
  • iv fluids
  • iv benzyl penicillin
  • consider iv dexamethasone
  • discharge home on a 10 day course of either:
    • oral phenoxymethylpenicillin (Pen V) bd (qid is not needed) but this needs to be taken before food
    • oral amoxycillin tds, better absorbed and better compliance but do not use if suspect EBV / glandular fever / infectious mononucleosis as a rash is likely to occur, and being broad spectrum, is more likely to cause diarrhoea or thrush and general antibiotic resistance issues than Pen V - thus this is NOT recommended as 1st line Rx.
    • if allergic to penicillins, then oral cephalexin qid, or if severe allergy, consider a macrolide such as roxithromycin
  • if suspect or proven EBV / glandular fever / infectious mononucleosis then warn about avoiding contact sports as risk of splenic rupture if enlarged.