What is the appropriate management for a 22-year-old male presenting with intermittent fever, dizziness, malaise, cervical lymphadenopathy, tender tonsillar lymph nodes, unilateral nasal turbinate swelling, erythematous tonsils, and a macular rash on the chest and back?

Acute Viral Syndrome with Possible Infectious Mononucleosis

This presentation is most consistent with a viral pharyngitis, likely infectious mononucleosis (EBV), and should be managed with supportive care only—antibiotics are not indicated and testing for group A streptococcus is not warranted given the clinical picture.

Why This is NOT Bacterial Pharyngitis

The clinical presentation argues strongly against group A streptococcal pharyngitis, which would be the only bacterial infection requiring antibiotics:

• Absence of tonsillar exudates is a key distinguishing feature—streptococcal pharyngitis typically presents with tonsillopharyngeal exudates 1
• Presence of a macular rash makes SARS and other viral causes more likely, as rash, lymphadenopathy and systemic symptoms suggest a viral rather than streptococcal etiology 1
• Posterior cervical lymphadenopathy is characteristic of infectious mononucleosis (EBV), not streptococcal pharyngitis which typically causes anterior cervical adenitis 1
• Unilateral nasal turbinate swelling suggests viral upper respiratory infection rather than bacterial pharyngitis 1
• Absence of high fever (>39°C) with purulent discharge makes bacterial sinusitis unlikely 1

Clinical Features Suggesting Viral Etiology (Likely EBV)

This constellation strongly suggests infectious mononucleosis:

• Posterior cervical chain lymphadenopathy is a hallmark of EBV infection 1
• Generalized lymphadenopathy (posterior cervical and tonsillar nodes) with systemic symptoms (fever, malaise, dizziness) 1
• Macular rash on trunk is consistent with viral exanthem, particularly EBV 1
• Erythematous tonsils without exudates can occur in viral pharyngitis 1
• Intermittent fever pattern over 4 days is more consistent with viral illness 1

Appropriate Management Strategy

Supportive care is the only indicated treatment:

• Analgesics for pain relief: acetaminophen or NSAIDs for throat pain and fever 1, 2
• Adequate hydration and rest 3
• Symptomatic relief: throat lozenges, salt water gargles 1
• No antibiotics indicated: this is a viral syndrome and antibiotics provide no benefit and cause harm through adverse effects 1

Critical Pitfall to Avoid

Do NOT prescribe amoxicillin or ampicillin if infectious mononucleosis is suspected—these antibiotics cause a characteristic maculopapular rash in 80-90% of patients with EBV infection, which can complicate the clinical picture and cause unnecessary patient distress 1.

When to Consider Testing

Testing for group A streptococcus would only be warranted if the patient had 1:

• Tonsillopharyngeal exudates (absent in this case)
• Anterior cervical adenitis (this patient has posterior chain involvement)
• Absence of viral features like cough, rhinorrhea, or rash (this patient has rash and nasal symptoms)

Follow-Up Recommendations

• Reassure the patient that viral pharyngitis symptoms typically last up to 2 weeks 1
• Return precautions: seek immediate care if symptoms worsen, high fever develops (>39°C), difficulty breathing, severe headache, or inability to swallow 1, 3
• Expected course: gradual improvement over 1-2 weeks with supportive care alone 1
• Consider monospot or EBV serology if symptoms persist beyond 2 weeks or if splenomegaly develops on examination 1