What is the best course of treatment for a patient with severe sore throat, headache, body aches, cough, and runny nose with a negative strep test, followed by swollen lymph nodes and multiple cold sores on the lower lip?

Management of Recurrent Viral Pharyngitis with Herpes Simplex Reactivation

This patient has viral pharyngitis with herpes simplex virus (HSV) reactivation, and treatment should focus on symptomatic relief with analgesics and consideration of antiviral therapy for the cold sores—antibiotics are not indicated given the negative strep test and viral presentation.

Clinical Reasoning

The clinical picture strongly suggests a viral illness rather than bacterial infection:

• The initial presentation with cough, runny nose, headache, and body aches indicates a viral upper respiratory infection, not streptococcal pharyngitis 1
• The negative strep test effectively rules out Group A Streptococcus (GAS), which is the only bacterial cause requiring antibiotic treatment 1
• The subsequent development of multiple cold sores (herpes labialis) on the lower lip represents HSV reactivation, likely triggered by the viral illness and immune stress 2, 3
• Swollen lymph nodes are consistent with viral pharyngitis and HSV infection 2, 4

Key diagnostic point: Patients with viral pharyngitis characteristically present with cough, nasal congestion, and other upper respiratory symptoms—features that make bacterial infection unlikely 1, 2. The presence of oropharyngeal vesicles or cold sores further confirms viral etiology 4, 3.

Recommended Treatment Approach

Symptomatic Management (Primary Treatment)

• Provide analgesics for pain and fever control: Either ibuprofen or acetaminophen should be given for throat pain, headache, and body aches 5, 6
• Both medications have equivalent efficacy for acute sore throat symptoms 6
• Adequate analgesia is essential to maintain comfort and oral intake 5
• Encourage hydration with cool liquids to soothe the throat and prevent dehydration 5, 2

Antiviral Therapy for Cold Sores

• Consider valacyclovir for the herpes labialis: The FDA-approved regimen is valacyclovir 2 grams twice daily for 1 day, initiated at the earliest symptoms 7
• Treatment shortens the duration of cold sore episodes by approximately 1 day compared to placebo 7
• Most effective when started within 2 hours of symptom onset, though still beneficial if started early in the course 7
• Alternative: The 2-day regimen (valacyclovir 2 grams twice daily on Day 1, then 1 gram twice daily on Day 2) does not offer additional benefit over the 1-day regimen 7

What NOT to Do

• Do not prescribe antibiotics: This patient has 0-2 Centor criteria (no fever mentioned currently, cough present, no exudates described, lymphadenopathy present but in context of viral illness) 1
• Antibiotics should not be used in patients with less severe presentations and negative strep testing 1, 5
• Treating viral pharyngitis with antibiotics provides no benefit and increases risks of side effects and antimicrobial resistance 5, 2
• Avoid aspirin if this were a child, due to Reye syndrome risk 5

Clinical Pitfalls to Avoid

• Misinterpreting lymphadenopathy as bacterial infection: Swollen lymph nodes occur commonly with viral pharyngitis, HSV infection, and Epstein-Barr virus 2, 4
• Generalized lymphadenopathy with splenomegaly would suggest infectious mononucleosis (EBV), but localized cervical adenopathy is consistent with simple viral pharyngitis 2, 4
• Overdiagnosing streptococcal pharyngitis: Physicians overdiagnose strep throat by a wide margin, leading to unnecessary antibiotic use 8
• The negative strep test is definitive—do not treat empirically 1
• Missing HSV pharyngitis: HSV can cause pharyngitis in adults and cannot easily be distinguished clinically from other causes of acute pharyngitis 3
• In college-age students, HSV was found in 5.7% of those presenting with upper respiratory complaints, with most having pharyngeal erythema 3

When to Reassess or Refer

• If fever persists beyond 3 days despite symptomatic treatment, consider alternative diagnoses or complications 5, 2
• Development of severe symptoms such as difficulty swallowing, drooling, neck tenderness/swelling, or breathing difficulties requires urgent evaluation for peritonsillar abscess, retropharyngeal abscess, or epiglottitis 1, 4
• Inability to maintain oral hydration or signs of dehydration warrant closer follow-up 5
• Persistent or worsening symptoms beyond 7-10 days may indicate a secondary bacterial infection or alternative diagnosis 2

Expected Clinical Course

• Viral pharyngitis typically resolves within 7-10 days with symptomatic treatment alone 1
• Cold sores treated with valacyclovir heal approximately 1 day faster than untreated lesions 7
• Symptoms should steadily improve with supportive care—lack of improvement suggests need for reassessment 5, 2