Differential Diagnosis for Bacterial vs Viral URI in Children

When evaluating a child with symptoms of an upper respiratory infection (URI), it's crucial to differentiate between bacterial and viral causes to provide appropriate treatment and prevent unnecessary antibiotic use. The following differential diagnosis is organized into categories to help guide clinical decision-making.

• Single Most Likely Diagnosis
  • Viral URI: This is the most common cause of URI symptoms in children, such as runny nose, cough, and sore throat, often due to rhinoviruses, coronaviruses, adenoviruses, and respiratory syncytial virus (RSV).
• Other Likely Diagnoses
  • Bacterial pharyngitis (Strep throat): Caused by Group A beta-hemolytic Streptococcus (GABHS), it presents with sore throat, fever, and swollen lymph nodes, and is more common in school-aged children.
  • Acute otitis media (AOM): A bacterial infection of the middle ear, often following a viral URI, presenting with ear pain, fever, and irritability.
  • Acute sinusitis: A bacterial infection of the sinuses, which can follow a viral URI, characterized by persistent nasal discharge, facial pain, and cough.
• Do Not Miss Diagnoses
  • Epiglottitis: A rare but potentially life-threatening bacterial infection of the epiglottis, presenting with severe sore throat, difficulty swallowing, and respiratory distress.
  • Retropharyngeal abscess: A bacterial infection in the tissues at the back of the throat, which can cause severe neck pain, difficulty swallowing, and respiratory distress.
  • Mastoiditis: A bacterial infection of the mastoid bone, which can complicate AOM, presenting with fever, ear pain, and swelling behind the ear.
• Rare Diagnoses
  • Lemierre's syndrome: A rare condition characterized by a bacterial infection of the tonsils, followed by septic thrombophlebitis of the internal jugular vein, presenting with severe sore throat, fever, and neck pain.
  • Tuberculosis (TB): A bacterial infection that can cause chronic cough, fever, and weight loss, although it is less common in children in many parts of the world.
  • Influenza: While not rare, it's included here because it requires specific consideration due to its potential for severe disease and the availability of antiviral treatments, presenting with high fever, cough, and body aches.

Each of these diagnoses has distinct clinical features and requires a tailored approach to diagnosis and treatment. Accurate differentiation between viral and bacterial URIs, as well as the identification of more serious conditions, is essential for providing appropriate care and preventing complications.