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

Management of Viral Pharyngitis with Herpes Simplex Reactivation

This patient has viral pharyngitis with herpes simplex virus (HSV) reactivation and does not require antibiotics—treat symptomatically with analgesics and consider antiviral therapy for the cold sores. 1, 2

Clinical Reasoning

The clinical presentation strongly indicates viral etiology rather than bacterial infection:

• Cough and runny nose are key indicators of viral infection and argue strongly against Group A Streptococcus (GAS), which typically presents without upper respiratory symptoms 1
• The negative strep test definitively rules out GAS, the only bacterial cause requiring antibiotic treatment 1, 2
• Multiple cold sores (herpes labialis) on the lower lip represent HSV reactivation, commonly triggered by viral upper respiratory infections 3, 4
• Swollen lymph nodes occur commonly with both viral pharyngitis and HSV infection and should not be misinterpreted as bacterial infection 2, 4

Recommended Treatment Approach

First-Line Symptomatic Management

Provide analgesics for throat pain, headache, and joint pain:

• Ibuprofen or paracetamol (acetaminophen) are equally effective for acute sore throat symptoms 1, 5
• Both medications are safe for short-term use with low risk of adverse effects 5, 2
• Ibuprofen may have slightly better efficacy for pain relief, particularly after 2 hours 5

Antiviral Therapy for Cold Sores

Consider valacyclovir for the herpes labialis:

• High-dose valacyclovir (2 g twice daily for 1 day) reduces episode duration by approximately 1 day when initiated at first symptoms 3
• This regimen significantly reduces healing time and time to cessation of pain compared to placebo 3
• Treatment is safe and well-tolerated with adverse events similar to placebo 3
• Alternative: topical acyclovir 5% with hydrocortisone 1% cream can reduce both ulcerative and non-ulcerative HSV recurrences 6

Supportive Care

• Encourage hydration with cool liquids to soothe the throat and prevent dehydration 2
• Adequate analgesia is essential to maintain comfort and oral intake 2

What NOT to Do

Do not prescribe antibiotics:

• Antibiotics provide no benefit for viral pharyngitis with negative strep testing and increase risks of side effects and antimicrobial resistance 1, 2
• The presence of cough and nasal symptoms makes bacterial infection highly unlikely 1, 2
• Even in bacterial pharyngitis, antibiotics only shorten symptom duration by approximately 1 day 7

Avoid unnecessary interventions:

• Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects 1, 5
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended 1, 5
• Corticosteroids are not indicated for this presentation (patient has 0-2 Centor criteria given the presence of cough) 1, 5

Expected Clinical Course

• Viral pharyngitis typically resolves within 7-10 days with symptomatic treatment alone 2
• Symptoms should steadily improve with supportive care; lack of improvement suggests need for reassessment 2
• About 90% of patients are free of symptoms by one week regardless of treatment 7

Key Clinical Pitfalls to Avoid

Do not misinterpret lymphadenopathy as bacterial infection:

• Swollen lymph nodes are a normal response to viral pharyngitis and HSV infection 2, 4
• The negative strep test is definitive—do not override it based on physical findings 1, 2

Do not overdiagnose streptococcal pharyngitis:

• The combination of cough, rhinorrhea, and negative strep test makes GAS extremely unlikely 1
• Testing for GAS is not even recommended when viral features are this prominent 1