Week 5

C H A P T E R 3 2

Sore throat Sore throat, or pharyngitis, is one of the most common concerns of patients in primary care. It is most often a transient condition of viral origin (adenoviruses, coxsackie A viruses, influenza, or parainfluenza virus). Throat pain is the result of an inflammation of the mucosa of the oropharynx, secondary to an infectious cause (e.g., viral, bacterial, fungal, or spirochetal). Less commonly, sore throat may be a symptom of systemic illness, such as mononucleosis. The posterior pharynx is also vulnerable to environmental irritants and drainage from the nose and sinuses. Thus pharyngitis begins as an inflammation of the mucous membranes with secondary involvement of the lymph node drainage system, rarely progressing to deep neck and mediastinal involvement. Throat pain can also be referred from other structures, most commonly the ears and thyroid gland.

Sore throats can be classified according to whether or not pharyngeal ulcers are present. This will sort out those relatively few sore throats caused by specific viral or fungal infections that produce pharyngeal ulcers and those caused by agents and processes characterized by an absence of pharyngeal ulcers.

The goals of assessment and diagnosis are to identify those patients with group A β­hemolytic streptococcus (GAS) infection and those with epiglottitis. Patients with GAS infection are at risk for rheumatic fever and glomerulonephritis, and timely treatment can reduce the possibility of sequelae of peritonsillar and retropharyngeal abscess. GAS is the most common bacterial cause of acute pharyngitis, responsible for 10% of sore throat visits in adults and 30% in children, especially during winter months.

Diagnostic reasoning: Focused history Is this an emergency? Key Questions

• Have you been drooling? • Have you been unable to swallow? • Have you been unable to lie down? • Have you been restless, unable to stay still? • Have you been unable to talk?

History The previous symptoms signal acute epiglottitis. The history is usually elicited from another individual because the patient is either a child or too ill to talk. Acute epiglottitis is rare: its incidence is 10 in 100,000 in children younger than 15 years and 1 to 8 in 100,000 in adults. The morbidity and mortality that result from airway obstruction, however, are significant.

Associated symptoms Symptoms and signs of epiglottitis are sore throat, difficulty swallowing, dyspnea, drooling, and inspiratory stridor. Haemophilus influenzae type b (Hib) is the most common pathogen, although it is decreasing in vaccinated children. The incidence of H. influenzae type B (Hib) epiglottitis is highest in children ages 2 to 5 years. Epiglottitis is a rapidly progressive illness with a potentially fatal outcome and must be recognized and referred immediately.

Severe throat pain with trismus and refusal to speak indicates severe peritonsillitis, which may lead to peritonsillar abscess formation (quinsy). Peritonsillar abscess is also an acute infection that needs to be identified immediately for referral and treatment. The symptoms of peritonsillar abscess and cellulitis include a

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severe sore throat, odynophagia, trismus (spasm of the masticatory muscles and difficulty opening the mouth), and medial deviation of the soft palate and peritonsillar fold. These symptoms are caused by infection penetrating the tonsillar capsule and surrounding tissues. About 30% of patients with peritonsillar abscess require an emergency tonsillectomy.

What does the presence of fever tell me? Key Questions

• Have you had a fever? • When did it start? • How high has it been?

Patterns of fever Fever is almost always present with GAS and is the most commonly occurring symptom in children. The fever is of sudden onset and the temperature rises above 38.5°C (101.5°F) with malaise, headache, and painful swallowing. Fever is also present in children and adults with epiglottitis. Influenza is characterized by the abrupt onset of fever, with temperatures typically ranging from 37.8° to 40°C (100° to 104°F). Children with adenoviral infection can be afebrile or have a fever greater than 40°C (104°F). Patients with Epstein­Barr virus (EBV) have a low­grade fever.

Fever, followed by an interval of several days without fever and then recurrent fever, or a continuing fever for several days may indicate peritonsillar abscess.

The absence of fever may also suggest a noninfectious cause, such as candidiasis and aphthous stomatitis.

Is the sore throat related to an infectious cause? Key Questions

• Is anyone else at home sick? • Are any of your friends or coworkers sick? • When did the pain start? • How severe is the pain?

Exposure Exposure to other ill individuals increases the likelihood of viral or bacterial infection. Respiratory illness caused by GAS is spread within families, with approximately 20% of family members becoming infected. EBV is not highly contagious and requires intimate contact between susceptible individuals and symptomatic shedders of the virus. Transmission is primarily through saliva.

Onset The sudden onset of sore throat is often caused by GAS. The organisms invade the pharyngeal epithelium, where they multiply and cause an intense immune response. Gradual onset is more common in infectious mononucleosis. The EBV infects B lymphocytes of the pharynx with resultant dissemination throughout the lymphoreticular system (also referred to as the reticuloendothelial system or the mononuclear phagocytic system), causing an immune response that is more gradual in onset.

In viral pharyngitis, a sore throat begins a day or two after the onset of other illness symptoms, reaching its peak by the second or third day.

Noninfectious causes of sore throat typically have an insidious onset. The patient often is not able to pinpoint when the sore throat started but notes that it has been persistent.

Severity Throat pain associated with streptococcal infection is usually intense. Throat pain associated with influenza and adenovirus is severe, with prominent edema of the throat. The throat pain produced by noninfectious causes tends to be less severe and may be described as “scratchy” or “annoying.”

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Young children may not be able to express the sensation of a sore throat or the severity of it. Instead, they may refuse to eat or drink.

What does the presence of upper respiratory tract symptoms tell me? Key Questions

• Do you have a cough? • Have you had a runny nose? If so, what color is the drainage? • Do you have postnasal drip?

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• Do you have eye redness or discomfort? • Have your eyes been itchy or watery? • Have you been hoarse? • Have you been sneezing? • Have you been wheezing?

Cough and rhinorrhea Cough, rhinitis, conjunctivitis, and hoarseness rarely occur with streptococcal pharyngitis, and the presence of two or more of these signs or symptoms most often suggests a viral infection.

Influenza is often associated with several days of fever, cough, and rhinorrhea. Viral pharyngitis is characterized by a sore, scratchy throat, nasal congestion, rhinorrhea, and cough. Clear nasal discharge is common in allergic pharyngitis and may produce postnasal drip that causes a sore throat.

Conjunctivitis Conjunctivitis rarely occurs with streptococcal pharyngitis. Mild conjunctivitis is common with viral infection. Watery or itchy eyes are also associated with exposure to allergens.

Hoarseness Hoarseness is not uncommon in allergy­associated sore throat and may be present with viral infection as well. Inflammation produces laryngeal edema that results in hoarseness. Hoarseness is not typically associated with GAS infection.

Sneezing Sneezing is common with both viral infection and allergen exposure. The sneezing associated with allergic pharyngitis is more persistent and is often seasonal.

Wheezing Wheezing can occur with exposure to allergens. When the body detects an allergen, it views it as a foreign body and tries to reject it by producing antibodies and histamine. Histamine causes a person’s airways to become inflamed and produce mucus. As a result, the airways become narrower. Air forced through a smaller space causes a whistling or wheezing sound.

What do the associated symptoms tell me? Key Questions

• Do you have muscle aches? • Have you had nausea, vomiting, or diarrhea?

Systemic symptoms Systemic symptoms, such as myalgia, are common in influenza and GAS infection. Streptococcal pharyngitis or influenza in children older than 2 years is associated with headache, abdominal pain, and vomiting. Fatigue, especially if prolonged, may indicate mononucleosis.

Influenza is often associated with several days of fever and systemic symptoms, such as myalgias, cough, and rhinorrhea. Common cold viruses associated with pharyngitis can also produce systemic symptoms such as myalgia.

Does the presence of risk factors help me narrow the cause? Key Questions

• How old are you? • What is your smoking history?

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• What kind of work do you do? • Do you engage in oral sex? • Are you taking medications? • Do you have any chronic health problems? • Are your immunizations up to date?

Age Group A streptococcal infection is primarily a disease in children 5 to 15 years of age. Influenza affects all ages; whereas parainfluenza and respiratory syncytial viruses (RSV) primarily affect children. Almost all children younger than 2 years of age will have RSV, and 25% to 40% will develop bronchiolitis or pneumonia.

Adenoviruses, the major viral agents isolated in exudative pharyngitis in younger children, are endemic. In military populations, adenovirus type 4 and, to a lesser extent, types 3, 7, and 21 are the most common causes of pharyngitis.

Adolescents and young adults are more likely than children and older adults to have a sore throat associated with mononucleosis caused by EBV. In older adults, mononucleosis often occurs without pharyngitis, adenopathy, or splenomegaly.

Irritant exposures Agents such as tobacco smoke, smog, dust, and allergens can irritate the throat. These agents cause mucosal irritation and set up the inflammatory process. People who work outdoors may have greater exposure to environmental allergens. Housekeepers have an increased risk of exposure to dust mites and chemical irritants.

Sexual behavior Pharyngitis from Chlamydia trachomatis or Neisseria gonorrhoeae is more prevalent in people with a history of orogenital sexual activity. Gonococcal pharyngitis is present in about 10% of patients with anogenital gonorrhea.

Medications and chronic health problems Immunosuppression increases susceptibility to viral agents that produce pharyngeal ulcers (e.g., herpangina, herpes simplex). People with diabetes and those taking broad­spectrum antibiotics are more susceptible to candidiasis. People with a history of gastroesophageal reflux disease may have a sore throat secondary to reflux of gastric contents.

Immunizations Infants receive the DTaP (diphtheria, tetanus, pertussis) and Hib vaccines as part of routine immunization. DTaP prevents diphtheria, tetanus, and pertussis. Hib prevents Hib responsible for epiglottitis in children. Adults should get a booster dose of Td every 10 years. Unimmunized children and adults are at higher risk for infection.

Diagnostic reasoning: Focused physical examination

Assess severity of illness Assessment of the patient begins with general observation about the severity of illness. Severe illness with signs of upper airway obstruction such as restlessness, stridor, difficulty breathing, drooling, inability to swallow, and high fever signals epiglottitis and requires immediate referral. Further physical examination with a tongue blade could trigger laryngospasms and lead to airway obstruction.

Inspect the mouth Examine the buccal mucosa, tongue, and sublingual area for the presence of ulcers. Note the location, number, size, and appearance of any lesions.

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The lesions produced by the group A coxsackievirus (herpangina) first appear as small, grayish, papulovesicular lesions on the soft palate and pharynx. They progress to shallow ulcers, usually less than 5 mm in diameter.

Vincent angina (necrotizing ulcerative gingivostomatitis) is a fusospirochetal infection of the gingiva. The gingiva appears inflamed and ulcerated, often covered with a gray slough. As the infection spreads, ulcers may appear on the oral mucosa and posterior pharynx.

Aphthous stomatitis, or canker sores, are lesions that affect about 20% of the general population and are associated with immunological mechanisms. They occur most often on the buccal mucosa, tongue, and soft palate. The lesions first appear as indurated papules and then progress to shallow ulcers. The ulcers have a yellow membrane and red halo.

Herpes simplex lesions involve the anterior oral mucosa and the gums. Herpetic pharyngitis is manifested by vesicles, ulcers, or exudate of the oral and pharyngeal mucosa. Specifically, the lesions involve the tonsils, pharynx, uvula, and edges of the soft palate. Vesicular lesions may or may not be intact.

Streptococcal infection in children may cause enlarged papillae on the tongue, which gives the tongue a strawberry appearance.

Inspect the posterior pharynx and observe swallowing Examine for edema, color, and exudate of the posterior pharynx, and determine the presence, size (Table 32.1), and condition of the palatine tonsils. Good visualization is critical for accurate diagnosis. Use a good light source and ask the patient to open wide and say “ah” but not to protrude the tongue. If you cannot

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view the pharynx, depress the tongue firmly with a tongue blade, far enough back to have a good view but not enough to cause the patient to gag. Use two tongue depressors to retract tissues medially and laterally when examining such areas as the retromolar region, the floor of the mouth, and the orifices of Wharton and Stensen ducts (Fig. 32.1). The best visualization is achieved with a headlight.

Table 32.1 Grading Tonsillar Size

GRADE TONSIL LOCATION

1 Behind pillars

2 Between pillars and uvula

3 Touching uvula

4 Extending beyond midline of oropharynx

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FIGURE 32.1 Anatomical structures of the mouth. Source: (From Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to physical examination, ed. 8, St. Louis, 2015, Elsevier.)

Drooling may indicate peritonsillar abscess or epiglottitis partially occluding the pharynx and esophagus. Only occasionally can the red, swollen epiglottis be visualized above the base of the tongue. If you suspect epiglottitis, do not examine the pharynx because manipulation may precipitate laryngospasms and airway obstruction. Refer the patient immediately for specialist evaluation and further tests, which may include soft tissue radiography of the head and neck and laryngoscopy.

Edema of the affected tonsil, with movement of the tonsil toward midline, indicates peritonsillar abscess. Diphtheria may appear as a thick, gray tonsillar exudate or pseudomembrane, spreading to the tonsillar pillars, uvula, soft palate, posterior pharyngeal wall, and larynx. The exudate is not easily removable and bleeds easily.

Pharyngeal or tonsillar exudate can be present with either a bacterial or a viral infection. A yellowish exudate of GAS pharyngitis is often present. Generally, the exudate of viral agents tends to be whiter than that from GAS.

A bright red uvula and the presence of petechiae on the posterior pharynx and palate indicate group A streptococcal pharyngitis. “Doughnut lesions,” or red, raised hemorrhagic lesions with a yellow center, are diagnostic of streptococcal pharyngitis.

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Postnasal drainage can irritate the posterior pharynx and should be observed for color. Purulent drainage that is yellow or greenish is associated with infectious sinusitis. White curdlike patches that bleed on scraping are characteristic of oral candidiasis.

When examination reveals normal findings, suspect a systemic referred cause for the sore throat, particularly acute otitis media, sinusitis, or thyroiditis.

Palpate the cervicofacial lymph nodes In streptococcal pharyngitis, the anterior cervical lymph nodes are often enlarged and tender. In viral infections, the posterior cervical nodes are more often enlarged. Lymphadenopathy is a cardinal sign of infectious mononucleosis, with more than 90% of patients having enlarged posterior cervical nodes.

Inspect the nasal mucosa Red, swollen turbinates indicate an infectious process; in contrast, pale, boggy turbinates indicate an allergic process. Mucoid discharge occurs in allergic rhinitis. Purulent discharge suggests infectious sinusitis.

Inspect the conjunctivae Injected conjunctivae associated with a sore throat may indicate pharyngoconjunctival fever. It is caused by an adenovirus and is often associated with nonpurulent discharge, fever, and pharyngitis. It frequently occurs in epidemics. Mild conjunctivitis in the presence of itching eyes and clear watery discharge is associated with an allergic process.

Inspect the tympanic membrane Evidence of otitis media with effusion may indicate atypical H. influenzae acute otitis media (conjunctivitis­otitis syndrome). Earache can be caused by referred pain, especially from the tonsils.

Palpate the thyroid Acute thyroiditis is associated with a sore throat, painful swallowing, and an enlarged or tender thyroid gland on palpation.

Inspect the skin Evidence of a fine maculopapular erythema that has a generalized distribution with accentuation in the skinfolds, circumoral pallor, and sparing of the palms and soles indicates scarlet fever. The rash characteristically is followed by a fine desquamation, starting at the hands.

Auscultate the lungs Mycoplasma pneumoniae is frequently associated with sore throat in adolescents and young adults. If pneumonia is present, palpation, percussion, and auscultation of the lungs reveal an area of consolidation and adventitious breath sounds (see Chapter 14 for further discussion of the lung examination).

E VI DEN C E- B ASE D P R A CT I CE

What Is the Current Evidence on Management of Peritonsillar Abscess? This literature review was limited to articles published from 1991 to 2011 and examined areas of controversy about peritonsillar abscess. Findings showed that (1) intraoral ultrasound has a sensitivity and specificity of between 89% and 95% and 79% and 100%, respectively, for correctly diagnosing peritonsillar abscess and is currently underused; (2) steroids can effectively aid recovery, reducing hospitalization time and improving symptom relief; however, further study is needed, especially related to the risk­to­benefit ratio (penicillin and metronidazole are an effective combination in at least 98% of cases of peritonsillar abscess); (3) there is no convincing evidence in favor of either aspiration or incision and drainage; tonsillectomy with an abscess present is safe and reduces overall recovery time when compared with tonsillectomy when symptoms are

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not present; (4) peritonsillar abscess can be effectively managed on an outpatient basis in many cases; and (5) the recurrence rate of peritonsillar abscess is poorly defined but estimated as 9% to 22%. Interval tonsillectomy may be indicated in patients at high risk of recurrence. The authors concluded that peritonsillar abscess is a common condition with increasing incidence. However, lack of consensus suggests that better evidence is needed for peritonsillar abscess management, especially for recurrence rates and different management strategies.

Reference: Powell and Wilson, 2012.

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Palpate the abdomen Splenomegaly is found in about half the cases of mononucleosis, although hepatomegaly is rare. Gastroesophageal reflux disease may be associated with palpable upper epigastric tenderness.

Laboratory and diagnostic studies The laboratory evaluation of sore throat is generally limited to the identification of GAS. Other infectious causes, such as gonorrhea or diphtheria, are rare, and testing is conducted only if the history indicates exposure. It is important to diagnose streptococcal pharyngitis so it can be treated promptly with antibiotics, avoiding serious sequelae, such as peritonsillar abscesses, rheumatic fever, or glomerulonephritis.

Rapid screening tests A throat swab is a rapid screen for streptococcal antigens and should be done if GAS is suspected. If it is positive, the patient is treated without follow­up cultures. If the swab result is negative, a throat culture is obtained. The test has a sensitivity of 75% to 85% and a specificity of 95% to 98%.

The Monospot is a rapid slide test that detects heterophil antibody agglutination; it is not specific for EBV. It is most sensitive 1 to 2 weeks after symptoms appear and remains positive for up to 1 year. If chronic fatigue syndrome is being considered as a differential diagnosis, specific EBV antibody tests should be considered.

Culture A throat culture to detect GAS is the gold standard of diagnosis, with a 10% or lower false­negative rate. When obtaining a culture, first remove crusts from lesions, taking care to touch only the throat or tonsils with the sterile swab. Avoid touching the tongue. Roll the throat swab over one tonsil, proceed across the posterior pharynx, and then swab the other tonsil. A culture can confirm a diagnosis of gonococcal pharyngitis.

Antistreptolysin O titer Group A β­hemolytic streptococcus produces enzymes that include streptolysin. An antistreptolysin O (ASO) titer is a serology test that detects the presence of a previous streptococcal infection. This titer does not increase until 1 to 6 months postinfection, so it is of no diagnostic value. It is used to aid in the diagnosis of streptococci­ associated infections, such as rheumatic fever, glomerulonephritis, and pericarditis. A caution, however, is that in as many as 50% of positive streptococcal cultures, an elevated ASO titer will not be found postinfection.

Potassium hydroxide smear for wet mount Obtain a sample of pharyngeal discharge using a cotton­tipped applicator. Using a microscope, examine the potassium hydroxide slide for branching and budding hyphae that are characteristic of yeast infection (see Chapter 37).

Complete blood count with differential Test results of 50% lymphocytes and at least 10% atypical lymphocytes support a diagnosis of mononucleosis; a positive monospot test result is diagnostic.

Computed tomography scan Suspicion of an obstruction or swelling of the throat should be referred for further evaluation with computed tomography.

Nasal smear Nasal cytology can be performed on secretions obtained by having the patient blow his or her nose into a paper or by using a cotton­tipped swab to obtain secretions from the nose. The presence of eosinophils on a nasal smear stained with Wright stain viewed under a high­power microscope suggests an allergic, inflammatory process.

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Differential diagnosis

Pharyngitis without ulcers

Epiglottitis Epiglottitis is caused by infection with Hib that produces inflammation and edema of the epiglottis and the surrounding areas, obstructing the flow of air. The edematous epiglottis may be pulled into the larynx during inspiration and can completely occlude the airway. Symptoms are respiratory distress, sore throat, difficulty with secretions, drooling, pain on swallowing, and a toxic appearance. The infection occurs in both children and adults.

Peritonsillar or retropharyngeal abscess A peritonsillar abscess, also called quinsy, is a collection of pus between the tonsil and the capsule of the tonsillar pillar. This condition occurs in children but is more common in adults, especially in people with a history of recurrent tonsillitis. The patient’s presenting concerns usually include a history of respiratory symptoms, difficulty swallowing, otalgia, malaise, fever, and cervical lymphadenopathy. On examination, there may be trismus; asymmetrical swelling of the uvula, tonsils, or posterior pharynx; or a visible abscess. Children’s presenting symptoms typically include fever, toxic appearance, refusal to swallow, drooling, and stridor. Children with retropharyngeal abscess are usually under the age of 4 and need immediate referral.

Viral pharyngitis Most sore throats are caused by viral infections. Patients usually have symptoms of malaise, fever, headache, cough, and fatigue. The pharynx is usually erythematous, or it may be pale, boggy, and swollen. There usually is no tonsillar enlargement or pharyngeal exudate, although infection with an adenovirus may produce exudate. The presence of concomitant upper respiratory tract symptoms such as cough and congestion makes the diagnosis of viral pharyngitis more likely than that of streptococcal pharyngitis. Common cold viruses cause sore throats most frequently during the colder months of the year.

Streptococcal pharyngitis The major differential diagnoses for sore throat will be viral or bacterial infection. About 10% of adults and 30% of children who seek care for sore throat symptoms, especially during winter months, have streptococcal tonsillopharyngitis. However, reliance on clinical impression to arrive at a specific diagnosis is problematic. The symptoms most likely to occur with streptococcal pharyngitis include a fever with a temperature of 38.5°C (101.5°F) or higher, tonsillar exudate, anterior cervical adenopathy, and a history of recent exposure. The incidence of streptococcal pharyngitis increases from 10% in the summer and fall to 40% during the winter and early spring. GAS cannot be reliably diagnosed on the basis of signs and symptoms, and even when cultures are obtained, a causative agent may not be identified in 50% of patients. Table 32.2 shows the groups at risk for GAS.

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Table 32.2 Groups at Risk for Group A β-Hemolytic Streptococcus (GAS) Pharyngitis

RISK FACTORS DIAGNOSTIC TESTS

HIGH RISK

Tonsillar exudate Temperature >38.5°C (101.5°F) Cervical lymphadenopathy Absence of cough Existing valvular rheumatic heart

disease

None; treat on basis of risk factors

PRESUMED STREP

Scarlet fever Strep epidemic Antibiotics already started

None; treat

MEDIUM RISK

Exudate, nodes, or fever present Prior rheumatic fever “Low risk” by PE but younger than 25

yr old and no URI Person with diabetes Recent “strep” exposure

Rapid strep screen; if positive, treat; if negative, culture; treat if culture positive; do not treat if culture negative

LOW RISK

No exudate, nodes, or fever Rapid strep screen; if positive, treat; if negative, do not culture; do not treat if culture negative

PE, physical examination; URI, upper respiratory tract infection.

Mononucleosis Mononucleosis causes about 5% of sore throats. It occurs most often in young adults, and the causative agent is EBV in more than 90% of cases. History typically reveals a gradual onset, low­grade fever, mild sore throat, posterior cervical lymphadenopathy, weight loss, and pronounced malaise and fatigue. Diagnosis can be confirmed with a positive Monospot test and a complete blood count that shows greater than 50% lymphocytosis. Splenomegaly occurs in about 50% of cases, and palatine petechiae are a less common symptom. GAS occurs concomitantly in 10% to 20% of cases.

Gonococcal pharyngitis This form of pharyngitis can occur in patients with a history of orogenital sexual activity. The patient may have no symptoms. Examination shows an exudative pharyngitis with bilateral cervical lymphadenopathy. Gram staining or culture will confirm the diagnosis.

Inflammation Inflammatory sore throat occurs in the presence of sinusitis or exposure to local irritants. The patient often reports postnasal drip and allergic symptoms (itchy, watery eyes, runny nose) that may follow seasonal patterns. On examination, the patient may have sinus

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tenderness. The pharynx may be swollen or pale with posterior drainage present. The patient does not have fever or lymphadenopathy.

Pharyngitis with ulcers

Herpangina Herpangina is an infection caused by the coxsackievirus. The patient reports a painful sore throat, fever, and malaise. Headache, anorexia, and neck, abdomen, and extremity pain may occur. Within 2 days of onset, small, grayish, papulovesicular lesions appear on the soft palate and pharynx. These progress to shallow ulcers, usually less than 5 mm in diameter. Outbreaks occur during the summer months. Coxsackie virus peaks in August, September, and October, although some cases occur during the winter months. It is more common in children and in immunosuppressed patients. Diagnosis is based on symptoms and characteristic oral lesions. An antibody titer can confirm diagnosis.

Vincent angina Vincent angina is caused by a fusospirochetal infection that results in necrotizing ulcerative gingivostomatitis. The patient’s symptoms include painful ulcers, foul breath, and bleeding gums. Without secondary infection, there usually is no fever. On examination, gray, necrotic ulcers without vesicles are apparent on the gingivae and interdental papillae. Gram staining shows spirochetes and confirms the diagnosis.

Aphthous stomatitis Aphthous stomatitis, or “canker sores,” appears as discrete ulcers without preceding vesicles. The ulcers are located on the inner lip, tongue, and buccal mucosa. Lesions last about 1 to 2 weeks. The cause of the lesions is unknown, but immunologic mechanisms play a major role.

Herpes simplex virus type 1 An infection from herpes simplex virus type 1 (HSV­1) is associated with fever, headache, sore throat, and lymphadenitis. Characteristic clusters of yellow vesicles appear on the palate, pharynx, and gingiva. Lesions last 2 to 3 weeks. Recurrent lesions are characterized by prodromal symptoms of burning, tingling, or itching. Active lesions are usually painful. Recent studies indicate that HSV­1 infections afflict about 30% to 90% of the US population.

Candidiasis Candidiasis is a yeast infection that produces white plaques over the tongue and oral mucosa with erythema; the plaques bleed when scraped. Candida infection occurs commonly in otherwise normal infants in the first weeks of life; in immunocompromised people, including those with diabetes; and in people taking antibiotics or using inhaled steroids.

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DIFFERENTIAL DIAGNOSIS OF Common Causes of Sore Throat

CONDITION HISTORY

PHARYNGITIS WITHOUT ULCERS

Epiglottitis Sore throat, difficulty with secretions, odynophagia (seen in pediatric patients younger than 2 yr), unable to lie flat, unable to talk

Peritonsillar or retropharyngeal abscess

History of recurrent tonsillitis; sore throat, difficulty swallowing, respiratory tract symptoms, fever, malaise

Viral pharyngitis Scratchy, sore throat, malaise, myalgias, headache, chills, cough, rhinitis

Group A β­hemolytic streptococcal pharyngitis

Mononucleosis (Epstein­Barr virus)

Young adults; slow onset of malaise, low­grade fever, mild sore throat

Presence or absence of pharyngeal exudate, posterior cervical lymphadenopathy, splenomegaly

Positive Monospot; CBC with differential; >50% leukocytes

Gonococcal pharyngitis

History of orogenital sexual activity; may be asymptomatic

Inflammation

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Most common in people 5–15 yr old; known exposure; fall and winter season; sudden onset of fever, severe sore throat, and malaise; absence of cough and upper respiratory tract symptoms

PHYSICAL FINDINGS

Respiratory distress, drooling, toxic appearance; do not examine the pharynx

Orthopnea, dyspnea, symmetrical swelling, abscess, trismus

Erythema, edema of throat, tender posterior cervical nodes

Temperature >38.5°C (101.5° F); exudate; anterior cervical lymphadenopathy

Pharyngeal exudate; bilateral cervical lymphadenopathy

DIAGNOSTIC STUDIES

Refer immediately

Refer immediately: CT scan; head and neck radiographs; laryngoscopy

None

Positive rapid strep antibody screen; strep culture

Gram stain; gonorrhea culture

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Exposure to irritants; postnasal drip; allergic symptoms

PHARYNGITIS WITH ULCERS

Inflammation

Herpangina (coxsackievirus)

More common in children; immunosuppressed; painful throat; fever, malaise

Fusospirochetal infection (Vincent angina)

Poor oral hygiene; painful ulcers, foul breath, bleeding gums

Aphthous stomatitis

Herpes simplex infection

History of trauma to mucosa; pain, fever, headache

Oral trauma, ill­fitting dentures; painful ulcers varying in size; absence of other symptoms

Candidiasis Immunosuppressed; people taking antibiotics or with diabetes; sore mouth or throat

Sinus tenderness, pale or swollen pharynx, postnasal drainage visible, no fever or lymphadenopathy

Lymphadenopathy; small grayish papulovesicular lesions on soft palate and pharynx, progressing to shallow ulcers, usually <5 mm in diameter

Gray necrotic ulcers without vesicles on gingival margins and interdental papillae

Gram stain reveals spirochetes

Shallow ulcers, no vesicles; indurated papules that progress to 1­cm ulcers; ulcer has yellow membrane and red halo; no fever or nodes

Perioral lesions; lymphadenitis; vesicles on palate, pharynx, gingiva

Viral culture

Curdlike white plaques that bleed when scraped off

Potassium hydroxide smear shows hyphae; culture

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CBC, complete blood count; CT, computed tomography; STI, sexually transmitted disease.

Eosinophils in nasal secretions with allergies

Serology

None

6/13/2019