What to do for a 31yo female with RA on Hydroxyzine with intermittent sore throat and a painless lump on her throat?

Management of a 31-Year-Old Female with RA, Intermittent Sore Throat, and Neck Lump

This patient requires prompt evaluation for Group A Streptococcal pharyngitis with rapid antigen detection testing and consideration of possible tuberculosis or other serious conditions given her rheumatoid arthritis status and presence of a neck mass.

Initial Assessment

The patient presents with:

• 31-year-old female with rheumatoid arthritis on hydroxyzine
• Intermittent sore throat for three weeks
• Painless lump on the right side of neck
• No pain associated with the lump

Differential Diagnosis

1. Streptococcal pharyngitis with lymphadenopathy

   • Common cause of sore throat with associated lymphadenopathy
   • Requires testing for confirmation 1

2. Viral pharyngitis with reactive lymphadenopathy

   • Most common cause of sore throat (>60% of cases) 2
   • Usually self-limiting

3. Tuberculosis

   • Higher risk in immunocompromised patients (RA) 3
   • Can present with cervical lymphadenopathy and minimal symptoms

4. Neoplastic process

   • Less common but important consideration in persistent lymphadenopathy
   • Risk factors include smoking, alcohol use, and immunosuppression

Diagnostic Approach

Step 1: Clinical Assessment Using Centor Criteria

• Assess for fever by history
• Check for tonsillar exudates
• Evaluate for tender anterior cervical adenopathy
• Note presence/absence of cough 1

Step 2: Targeted Testing

• Rapid antigen detection test (RADT) if Centor score ≥3 1
• Throat culture if RADT negative but high clinical suspicion 1
• Neck ultrasound to evaluate the lump characteristics
• Consider tuberculosis screening given RA status and risk of reactivation 3

Treatment Algorithm

If Group A Streptococcal Pharyngitis Confirmed:

1. First-line treatment: Penicillin V 500 mg 2-3 times daily for 10 days OR Amoxicillin 500 mg twice daily for 10 days 1
2. For penicillin allergy (non-anaphylactic): Cephalexin 500 mg twice daily for 10 days 1
3. For penicillin allergy (anaphylactic): Clindamycin 300 mg three times daily for 10 days OR Azithromycin 500 mg once daily for 5 days 1

If Viral Pharyngitis:

• Symptomatic treatment with NSAIDs (first-line) or acetaminophen 1
• Warm salt water gargles and throat lozenges 1
• Reassurance that symptoms typically resolve within one week 2

If Neck Mass Persists or Concerning Features:

• Referral to ENT for further evaluation
• Consider biopsy if mass persists after treatment of infection

Important Considerations

Rheumatoid Arthritis Implications

• Patients with RA have increased susceptibility to infections
• Risk of tuberculosis reactivation, especially if on immunosuppressive therapy 3
• Hydroxyzine (antihistamine) may mask some symptoms but doesn't significantly alter infection risk

Common Pitfalls to Avoid

1. Treating empirically with antibiotics without testing - Most sore throats are viral and don't require antibiotics 2, 1
2. Ignoring the neck mass - Persistent lymphadenopathy requires evaluation, especially in immunocompromised patients
3. Incomplete antibiotic course - Full 10-day course is essential to prevent complications if GAS is confirmed 1
4. Missing tuberculosis - Consider TB in RA patients with persistent lymphadenopathy 3

Red Flags Requiring Urgent Attention

• Difficulty swallowing or breathing
• Drooling or inability to handle secretions
• Neck swelling with limited range of motion
• Trismus (lockjaw)
• Systemic toxicity or high fever

Follow-up Recommendations

• Re-evaluation in 48-72 hours if symptoms persist or worsen on therapy
• Follow-up imaging of neck mass if it doesn't resolve with antibiotic treatment
• Consider ENT referral if mass persists beyond 2-3 weeks despite appropriate therapy