What is the appropriate treatment for an 18-year-old female presenting with fever, chills, neck pain, headache, sore throat with white plaque, and congestion, with negative mononucleosis (mono), coronavirus disease 2019 (COVID-19), influenza, and streptococcal (strep) tests?

Treatment for 18-Year-Old Female with Fever, Chills, Neck Pain, Headache, Sore Throat with White Plaque, and Congestion

For an 18-year-old female presenting with fever, chills, neck pain, headache, sore throat with white plaque, and congestion, with negative tests for mono, COVID-19, influenza, and strep, empiric treatment with azithromycin is recommended as the most appropriate first-line therapy to address the likely bacterial pharyngitis or tonsillitis.

Initial Assessment and Diagnosis

• The constellation of symptoms (fever, chills, neck pain, headache, sore throat with white plaque, and congestion) suggests an upper respiratory tract infection with possible bacterial pharyngitis/tonsillitis despite negative rapid tests 1
• White plaque on the tonsils is particularly concerning for a bacterial infection, even with negative strep test (which can have false negatives) 1
• The negative tests for common viral etiologies (mono, COVID-19, influenza) increase the likelihood of bacterial etiology or less common viral infection 1

Treatment Algorithm

First-Line Treatment

1. Antibiotic Therapy

   • Azithromycin is recommended as first-line therapy for suspected bacterial pharyngitis/tonsillitis when strep test is negative but clinical suspicion remains high 1
   • Alternative options include amoxicillin or fluoroquinolones if azithromycin is contraindicated 1

2. Symptomatic Treatment

   • For fever >38.5°C: Ibuprofen 200mg orally every 4-6 hours (not exceeding 4 times in 24 hours) 1
   • Adequate hydration and nutrition with protein-rich foods to support immune function 1, 2

Adjunctive Therapy

• Consider short-course corticosteroids (e.g., methylprednisolone) if significant throat swelling or difficulty swallowing is present 1, 3
• Anticholinergic medications may help reduce respiratory secretions if congestion is severe 1

Special Considerations

• Airway Monitoring: Though rare, patients with severe pharyngitis/tonsillitis can develop airway compromise requiring urgent intervention 3, 4
• Follow-up: If symptoms do not improve within 48-72 hours of antibiotic therapy, re-evaluation is necessary to consider alternative diagnoses 1
• Atypical Presentations: Some viral infections like Epstein-Barr virus can present with similar symptoms and negative rapid tests 5

Common Pitfalls to Avoid

• Overlooking bacterial infection: Despite negative strep test, bacterial pharyngitis/tonsillitis remains possible, especially with white tonsillar plaque 6
• Overuse of broad-spectrum antibiotics: While antibiotics are indicated, avoid unnecessary combinations of broad-spectrum agents 1
• Inadequate pain control: Severe pharyngitis can significantly impact oral intake; ensure adequate analgesia 1
• Missing airway compromise: Though uncommon in otherwise healthy young adults, monitor for signs of respiratory distress 3

Monitoring and Follow-up

• Monitor vital signs, particularly temperature and respiratory rate 1
• Assess for improvement in symptoms within 48-72 hours of starting antibiotics 1
• Consider further diagnostic testing if no improvement with initial therapy 2

This approach prioritizes treating the most likely bacterial cause while providing symptomatic relief, with careful monitoring for potential complications that could affect morbidity and mortality.