Severe throat pain
A 27-year-old woman sought care for the sore throat, fever, and chills she’d been experiencing for the past 2 days. She was unable to swallow anything other than liquids because of the throat pain. She denied any congestion or cough. On examination, she had bilateral tonsillar erythema and exudate. Her anterior cervical lymph nodes were tender.
What's your diagnosis?
Based on the presence of fever, tender lymphadenopathy, and tonsillar exudate—and the absence of cough—the physician strongly suspected group A β-hemolytic Streptococcus (GABHS) pharyngitis and prescribed oral penicillin VK. GABHS accounts for 5% to 10% of pharyngitis in adults and 15% to 30% in children. Up to 38% of cases of tonsillitis are because of GABHS.
The following criteria are helpful in the diagnosis of GABHS pharyngitis:
○ history of fever or temperature of 38°C (100.4°F) (1 point)
○ absence of cough (1 point)
○ tender anterior cervical lymph nodes (1 point)
○ tonsillar swelling or exudates (1 point)
○ age: <15 years (1 point); 15 to 45 years (0 points); >45 years (–1 point).
The probability of GABHS is approximately 1% with –1 to 0 points and approximately 51% with 4 to 5 points.
Rapid antigen detection is often used to diagnose GABHS. Test options include enzyme immunoassays, latex agglutination, liposomal method, and immunochromatographic assays. The immunochromatographic assay has the highest reported sensitivity (97%), specificity (97%), and positive (32.3) and negative (0.03) likelihood ratios.
In this patient’s case, the likelihood of strep pharyngitis was high enough that a rapid strep test was not performed. For suspected or proven GABHS, penicillin VK 500 mg orally 2 to 3 times daily for 10 days continues to be the treatment of choice for adults. Erythromycin 500 mg orally 4 times daily may be used in penicillin allergic patients. Treatment should also include analgesics/antipyretics, as needed, plenty of fluids, and rest.
Photo courtesy of Michael Nguyen, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Williams, B, Usatine R, Smith M. Pharyngitis. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:213-219.
To learn more about the Color Atlas of Family Medicine, see: https://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/ref=dp_ob_title_bk
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