Pharyngitis

Pharyngitis Syndromes Associated With Specific Viruses

EBV pharyngitis during infectious mononucleosis can be severe, with pharyngeal findings identical to those of GAS pharyngitis ( Fig. 27.1A ). Severe exudative tonsillitis in conjunction with generalized lymphadenopathy, significant posterior cervical adenopathy, and splenomegaly with or without hepatomegaly should focus the clinician on EBV as the etiology. Acute upper respiratory obstruction can result from severe tonsillar hypertrophy and inflammation. Fever and pharyngitis typically last 1–3 weeks, whereas the lymphadenopathy and hepatosplenomegaly resolve over 3–6 weeks. Laboratory findings include atypical lymphocytosis ( Fig. 27.1B ), heterophile antibodies, viremia (detected by PCR), and specific antibodies to EBV antigens. Especially if amoxicillin has been given, an intense maculopapular rash can occur ( Fig. 27.1C ).

Primary oral HSV infections usually occur in young children and present with acute gingivostomatitis associated with ulcerating vesicular lesions throughout the anterior mouth and lips, sparing the posterior pharynx. Patients with HSV gingivostomatitis often have high fever; the illness takes up to 2 weeks to resolve. Pain can be intense, and poor oral intake can lead to dehydration. In adolescents and adults, HSV can cause mild pharyngitis that may or may not be associated with typical vesicular, ulcerating lesions.

Enterovirus infections (coxsackievirus, echovirus, and enterovirus) are associated with erythematous pharyngitis without tonsillar exudates or cervical lymphadenopathy. Fever can be prominent, but resolution usually occurs within a few days. Herpangina is a specific syndrome caused by coxsackievirus A or B or echoviruses, characterized by fever and painful, discrete, grey-white papulovesicular or ulcerative lesions on an erythematous base in the posterior oropharynx ( Fig. 27.2 ). Hand-foot-and-mouth disease is characterized by painful vesicles and ulcers throughout the oropharynx associated with vesicles on the palms, soles, and sometimes on the trunk or extremities. The most common agent is Coxsackie A16, but Enterovirus 71 and Coxsackie A6 can also cause hand-foot-and-mouth disease. Enteroviral lesions usually resolve within 7 days.

Adenovirus pharyngitis is associated with fever, erythema of the pharynx, enlarged tonsils with exudate, and enlarged cervical lymph nodes. The presence of conjunctivitis in association with pharyngitis is highly suggestive of the adenovirus syndrome called pharyngoconjunctival fever . Adenovirus pharyngitis can persist for up to 7 days and conjunctivitis (sometimes simulating periorbital cellulitis) up to 14 days, after which both resolve spontaneously. Outbreaks of pharyngoconjunctival fever have been associated with transmission in swimming pools. Widespread epidemics and sporadic cases also occur.

Early in measles the oropharynx can be intensely erythematous; the presence of the pathognomonic enanthem, Koplik spots, on the buccal mucosa opposite the first and second molars occurs 2–3 days before rash.

Infection with the novel coronavirus, SARS-CoV-2, can present with pharyngitis; 12.8% of US children ≤9 years and 28.6% of those 10–19 years report sore throat. Systemic infections with cytomegalovirus (CMV) and human immunodeficiency virus (HIV) can include pharyngitis.

Bacteria Other Than Group A Streptococcus

GCS and GGS pharyngitis typically resemble GAS pharyngitis and are diagnosed most commonly in adolescents and young adults. GCS pharyngitis can cause elevated levels of serum anti-streptolysin O (ASO) antibody. When sought, GCS is a relatively common cause of acute pharyngitis among college students and adults seeking urgent care. ^, Outbreaks of GCS pharyngitis related to consumption of contaminated food products, especially unpasteurized cow milk, have occurred in families and schools. Serious complications, including endocarditis and meningitis, have been described. A community-wide outbreak of pharyngitis among children was described in which GGS was isolated from 25% of 222 consecutive children with acute pharyngitis seen in a private pediatric office. Restriction enzyme analysis suggested that 75% of isolates belonged to the same GGS clone, implying person-to-person transmission. The role of GCS in acute, endemic pharyngitis remains unclear.

Arcanobacterium haemolyticum pharyngitis is a rare cause of pharyngitis among teenagers and young adults. It is generally indistinguishable from GAS pharyngitis and can manifest a fine red papular rash that resembles the rash of scarlet fever. Cohort studies of Arcanobacterium pharyngitis have not demonstrated occurrence of complications but numerous case reports describe associated sepsis and soft-tissue infections. A. haemolyticum does not grow well on sheep blood agar; many laboratories do not employ human or horse blood agar that is preferred for growth.

Fusobacterium necrophorum causes pharyngitis primarily in older adolescents and adults (15–30 years old). Prevalence has varied from 10% to 48% of patients in studies of non-GAS pharyngitis, but there have not been any large surveillance studies. F. necrophorum was detected by PCR in 20.5% of patients with pharyngitis in a study in a university health clinic and in 9.4% of a convenience sample of asymptomatic patients. Patients with pharyngitis and F. necrophorum detection had signs and symptoms similar to GAS pharyngitis: about one-third had fever, one-third had tonsillar exudates, two-thirds had anterior cervical lymphadenopathy, and most did not have cough. F. necrophorum is important as the cause of about 80% of cases of Lemierre syndrome, internal jugular vein septic thrombophlebitis. Patients with Lemierre syndrome present initially with fever, sore throat, exudative pharyngitis, and/or peritonsillar abscess, not unlike F. necrophorum PCR-positive pharyngitis cases observed in a university health clinic. Symptoms can persist, neck pain and swelling develop, and the patient appears toxic. In addition to development of septic shock, metastatic complications from septic emboli can involve the lungs, bones and joints, central nervous system, abdominal organs, and soft tissues. The case fatality rate of Lemierre syndrome is 4%–9%. F. necrophorum is difficult to isolate from a throat culture, and diagnostic testing with PCR is not generally available.

Gonococcal pharyngeal infections are most common in adolescents and adults related to oral—genital sexual contact. Pharyngeal infections usually are asymptomatic, but patients can have acute ulcerative or exudative pharyngitis with fever and cervical lymphadenitis. Young children with documented gonococcal disease must be evaluated for sexual abuse.

Diphtheria, caused by toxin-producing Corynebacterium diphtheriae , is endemic in many areas of the world, including countries in Eastern Europe, Africa, Asia, the Middle East, and Latin America. Immunization with diphtheria toxoid has made it rare in most developed countries; there are fewer than 5 cases reported annually in the US. From 2016 to 2019 diphtheria outbreaks occurred in Indonesia, Bangladesh, Myanmar, Vietnam, Venezuela, Haiti, South Africa, and Yemen. Diphtheria can be considered in patients with recent travel to or from an endemic area, especially if they are underimmunized. Key physical findings are bull neck (extreme neck swelling) and a gray pharyngeal pseudomembrane that can cause respiratory obstruction.

M. pneumoniae and C. pneumonia e cause pharyngitis but are infrequently recognized. Development of a severe or persistent cough subsequent to pharyngitis may be the clue to infection. Oropharyngeal tularemia results from ingestion of water, milk, or undercooked meat contaminated with Francisella tularensis. Severe throat pain, tonsillitis, cervical adenitis, oral ulcerations, and a pseudomembrane may be present.

Group A Streptococcus (See Also Chapter 118 )