What's the differential diagnosis for a 12-year-old presenting with sore throat and dizziness?

Differential Diagnosis for Sore Throat and Dizziness in a 12-Year-Old

The differential diagnosis must prioritize life-threatening conditions first, then common infectious causes, recognizing that this age group falls within the peak demographic for Group A streptococcal pharyngitis (5-15 years) but that most sore throats are viral. 1

Life-Threatening Conditions (Evaluate Immediately)

Acute epiglottitis presents with rapid symptom deterioration, toxic appearance, drooling, sitting position leaning forward, and dysphagia—dizziness may reflect hypoxia or impending airway compromise. 2 This requires immediate airway management with a low threshold for securing the airway. 2

Peritonsillar or retropharyngeal abscess can cause dizziness from sepsis, dehydration, or extension of infection. Look for unilateral throat pain, trismus, uvular deviation, "hot potato" voice, and toxic appearance. 3, 4, 5 These patients require hospitalization. 4

Lemierre's syndrome (Fusobacterium necrophorum) presents initially as severe pharyngitis with fever, followed by painful neck swelling and potential pulmonary symptoms—dizziness may indicate septic emboli or sepsis. 6 Exclusion of streptococcal infection does not exclude this bacterial cause. 6

Common Infectious Causes

Viral pharyngitis accounts for the majority of sore throat cases in children. 3 Key viral pathogens include:

• Influenza, parainfluenza, rhinovirus, coronavirus, adenovirus, respiratory syncytial virus 1
• Epstein-Barr virus (infectious mononucleosis) with generalized lymphadenopathy and splenomegaly 1, 3
• Enteroviruses and herpesviruses 1

Clinical clues favoring viral etiology: conjunctivitis, coryza, cough, diarrhea, hoarseness, oral ulcers. 1, 3 Dizziness in viral illness typically reflects dehydration, fever, or orthostatic changes. 1

Group A β-hemolytic streptococcal (GABHS) pharyngitis causes 15-35% of pharyngitis in children aged 5-15 years. 7 Clinical features include:

• Sudden-onset sore throat, pain with swallowing, fever (101-104°F) 1
• Tonsillopharyngeal erythema with or without exudates 1
• Anterior cervical lymphadenitis (tender nodes) 1
• Soft palate petechiae, beefy red swollen uvula 1
• Headache, nausea, vomiting, abdominal pain 1
• Scarlatiniform rash 1
• Winter/early spring presentation 1

Note that 10.9% of children aged 14 years or less are asymptomatic GABHS carriers, so positive testing may not indicate acute infection. 1, 7

Other Bacterial Causes

Groups C and G streptococci can cause severe pharyngitis with exudative tonsillitis and anterior cervical adenopathy, though antibiotic benefit is unproven. 3

Mycoplasma pneumoniae, Chlamydia pneumoniae, Arcanobacterium hemolyticum are less common bacterial causes. 1

Neisseria gonorrhoeae should be considered in sexually active adolescents. 1, 3

Dizziness-Specific Considerations

Dizziness in the context of sore throat may indicate:

• Dehydration from fever, poor oral intake, or vomiting 1
• Orthostatic hypotension from acute illness 1
• Sepsis or bacteremia (toxic appearance, altered mental status) 1, 2
• Hypoxia from airway compromise 2
• Acute otitis media complicating pharyngitis (vestibular symptoms) 1, 8
• Febrile seizures or encephalopathy (particularly with influenza) 1
• Meningitis (check for neck stiffness, photophobia, altered mental status) 1

Diagnostic Approach

Immediate assessment for airway compromise: stridor, inability to swallow secretions, drooling, toxic appearance, sitting position. 2, 3, 5 If present, secure airway immediately. 2

Vital signs and hydration status: fever, blood pressure (orthostatic changes), heart rate, oxygen saturation. 1

Throat examination: Look for tonsillopharyngeal erythema, exudates, uvular deviation (abscess), petechiae, lymphadenopathy. 1 Avoid aggressive examination if epiglottitis suspected. 2

Microbiological confirmation for GABHS: Perform rapid antigen detection test (RADT) or throat culture—clinical features alone cannot differentiate bacterial from viral pharyngitis. 1, 9 A positive RADT is diagnostic; negative RADT in children requires backup throat culture. 1

Do not test if clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis). 1

Management Algorithm

If life-threatening condition suspected: Immediate hospitalization, airway management, IV antibiotics. 2, 4, 5

If GABHS confirmed: Penicillin V or amoxicillin for 10 days. 1 Adjunctive therapy with acetaminophen or NSAIDs for fever and pain (avoid aspirin in children). 1

If viral pharyngitis: Supportive care with analgesics, antipyretics, hydration, reassurance about self-limited course. 3, 8 Antibiotics provide modest symptom reduction (NNTB = 6 at day 3,18 at week 1) but must be weighed against antimicrobial resistance. 8

Address dizziness: Ensure adequate hydration, treat fever, evaluate for orthostatic hypotension, and rule out complications like otitis media or meningitis. 1, 8

Common Pitfalls

Do not assume all positive GABHS tests indicate acute infection—up to 10.9% of this age group are asymptomatic carriers experiencing viral pharyngitis. 1, 7, 3

Do not delay airway management if epiglottitis is suspected—rapid deterioration can occur. 2

Do not miss peritonsillar abscess—unilateral symptoms, trismus, and toxic appearance require urgent evaluation. 3, 4

Do not ignore dizziness—it may indicate serious complications like sepsis, dehydration, meningitis, or hypoxia. 1, 2