What is the recommended treatment for a persistent sore throat lasting 2 weeks with no other symptoms in an adult?

Persistent Sore Throat for 2 Weeks Requires Further Evaluation

A 44-year-old male with sore throat persisting for 2 weeks falls outside the scope of acute pharyngitis guidelines and requires investigation for alternative diagnoses, as this duration exceeds the typical self-limited course and suggests a non-infectious or complicated etiology.

Critical Context: This Case Exceeds Guideline Parameters

The ESCMID guideline explicitly restricts recommendations to acute sore throat with duration of symptoms <14 days, and specifically excludes recurrent or persistent cases from their diagnostic and treatment algorithms 1. Your patient is at the 14-day threshold, which signals the need for a different approach than standard acute pharyngitis management.

Why This Duration Matters

• Most viral and bacterial pharyngitis resolves within less than one week, with the majority (>80%) achieving complete symptom resolution by 7 days 2, 3
• Even untreated streptococcal pharyngitis typically shows fever and constitutional symptoms disappearing within 3-4 days, with throat soreness lasting at most 1-2 days longer than antibiotic-treated cases 3
• Persistence beyond 2 weeks without other symptoms is atypical and warrants consideration of non-infectious causes 1, 4

Recommended Diagnostic Approach

Immediate Red Flag Assessment

Evaluate for serious complications that require urgent intervention:

• Peritonsillar abscess (quinsy): unilateral tonsillar swelling, uvular deviation, trismus, muffled voice 2
• Lemierre syndrome: severe pharyngitis with neck swelling, particularly in young adults, which requires urgent diagnosis 2
• Retropharyngeal abscess: difficulty swallowing, neck stiffness, systemic toxicity 4
• Epiglottitis: cherry-red epiglottis, respiratory distress 4

Consider Non-Infectious Etiologies

Given the prolonged duration without other symptoms, investigate:

• Thyroiditis: can present as isolated sore throat 4
• Gastroesophageal reflux disease: chronic throat irritation
• Chronic irritation: smoking, environmental exposures, mouth breathing
• Neoplastic processes: particularly in a 44-year-old male with isolated persistent symptoms
• HIV-related candidal infection: if risk factors present 4
• Gonococcal pharyngitis: if sexual exposure history suggests this 4

Diagnostic Testing Strategy

Do NOT apply standard acute pharyngitis testing algorithms (Centor criteria, rapid antigen tests) as these are designed for acute presentations <14 days 1, 2, 5.

Instead, perform:

• Direct laryngoscopy/pharyngoscopy: visualize posterior pharynx, larynx, and base of tongue
• Consider throat culture for atypical organisms if infectious etiology still suspected 4
• Monospot or EBV serology: if any lymphadenopathy present, even without other classic symptoms
• HIV testing: if any risk factors or unexplained findings 4

Symptomatic Management While Investigating

• Ibuprofen or paracetamol for pain relief, as these remain first-line analgesics regardless of etiology 1, 2
• Avoid empiric antibiotics without confirmed bacterial infection, as most persistent sore throats are not streptococcal 2, 6

Common Pitfalls to Avoid

• Do not assume this is simple streptococcal pharyngitis and prescribe antibiotics empirically—the 2-week duration makes this diagnosis unlikely 3, 6
• Do not apply Centor or FeverPAIN scores to persistent cases, as these tools are validated only for acute presentations 2, 6, 5
• Do not dismiss the patient with reassurance alone—the absence of other symptoms does not rule out serious pathology in a 2-week presentation 1
• Do not order rapid antigen testing as the primary diagnostic—this patient needs visualization and broader workup 1, 5

If Streptococcal Infection Is Ultimately Confirmed

Should testing reveal group A streptococcus despite the prolonged course:

• Penicillin V remains first-line: 250-500mg twice or three times daily for 10 days 2, 7, 5
• Amoxicillin alternative: 500mg every 12 hours or 250mg every 8 hours for 10 days 7
• Azithromycin for penicillin allergy: 500mg once daily for 3 days 8
• However, at 2 weeks duration, antibiotic benefit for symptom reduction is negligible as the natural course has already exceeded the 1-2 day benefit window 3