History and exam

Your Organisational Guidance

ebpracticenet urges you to prioritise the following organisational guidance:

Acute KeelpijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2017Mal de gorge aiguPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2017

Key diagnostic factors

common

presence of risk factors

Among the strong risk factors - nasal colonisation, contact with a person with group A Streptococcus, sexual activity or abuse, ingestion of non-domestic meats, and immunocompromise - nasal colonisation and contact with a person with GAS are common.

child or adolescent age

Acute group A Streptococcus pharyngitis is common in children and adolescents aged 5-15 years and rare in children aged <3 years.[4][26]

winter or spring season (in bacterial pharyngitis)

Acute group A Streptococcus pharyngitis is most frequent in the winter (or early spring) in temperate climates.[1]

summer/autumn season (in enteroviral pharyngitis)

Enteroviral pharyngitis is more common in the summer and autumn.[1][2]​​

rhinorrhoea, nasal congestion, hoarseness, oral ulcers, and cough (in viral infection)

Viral nasopharyngitis can be distinguished from group A Streptococcus pharyngitis by the presence of rhinorrhoea, nasal congestion, and cough.[4]

Absence of cough (with the presence of cervical adenopathy) has the highest specificity for predicting streptococcal aetiology.[27]

sore throat

Sore throat is a common symptom.[4]

pharyngeal exudate

The presence of a pharyngeal exudate is common in group A Streptococcus pharyngitis, but can also be seen in disease due to other agents including Epstein-Barr virus, other streptococci, and Francisella tularensis.

cervical adenopathy

Presence of painful anterior cervical adenopathy and absence of cough have the highest specificity for predicting streptococcal aetiology.[27]

fever

Fever is common in pharyngitis and is a non-specific symptom.

headache

May be present, especially in children.[1][4]​​

nausea, vomiting, and abdominal pain

May be present, especially in children.[1][4]​​

conjunctivitis

Common in measles and in pharyngitis due to viral infection.[4]

maculopapular rash (in measles)

Characteristic maculopapular rash is common in measles.

Koplik spots (in measles)

Koplik spots (bluish-white, raised lesions on an erythematous base on the buccal mucosa) are pathognomonic for measles.[6]

uncommon

scarlatiniform rash (in group A Streptococcus [GAS] pharyngitis)

Scarlatiniform rash may be present, especially in children, and is suggestive of GAS.[1]

Other diagnostic factors

uncommon

sexual activity or abuse (in HIV, gonorrhoeal, or chlamydial infection)

HIV, gonorrhoea, and chlamydia should be considered as causative organisms in sexually active or abused individuals with pharyngitis.[10]

treatment failure of penicillin

Treatment failure in a patient without laboratory confirmation of group A Streptococcus (GAS) should prompt culture for bacterial agents other than GAS, and examination for evidence of viral disease.

pharyngeal ulceration (in tularaemia)

Tularaemia should be suspected in the presence of ulcerations, exudates, and a history of ingestion of undercooked wild animal meat.[9][13][7]​ History may also include a historical failure of response to penicillin therapy.[8]

pharyngeal grey membrane (in diphtheria)

Diphtheria should be considered if a grey membrane is identified in the pharynx or nares.[Figure caption and citation for the preceding image starts]: Typical pseudomembrane of diphtheria pharyngitisCopyright Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong; used with permission [Citation ends].com.bmj.content.model.Caption@714addf9

Tularaemia may mimic membranous diphtheria.

Risk factors

strong

nasal colonisation with group A Streptococcus (GAS)

Pharyngitis is most common in the winter (or early spring), when nasopharyngeal colonisation with GAS reaches up to 20% of children.[1]

GAS-infected contact

Transmission of GAS pharyngitis from infected individuals to close contacts occurs frequently through saliva, wound exudates, or nasal secretions.[4]

sexual activity or abuse

HIV infection, chlamydia, and gonorrhoea should be considered as causes in sexually active or abused individuals with pharyngitis, especially in those with negative testing for GAS.[10]

ingestion of non-domestic meats

Tularaemic ulceroglandular pharyngitis is acquired from the ingestion of partially cooked wild animal meat.[9]​[5]​[7]​​

immunocompromised host

Candida pharyngitis is commonly seen in the presence of immunocompromise (e.g., after solid-organ transplantation or chemotherapy, and in individuals with HIV infection).

use of inhaled corticosteroids

Inhaled corticosteroids are associated with Candida pharyngitis. Patients may have pharyngeal involvement without overt oral thrush.[22]

lack of immunisation or vaccine failure

Lack of vaccination may predispose to diphtheria or measles.

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