What is the diagnosis and treatment for white patches and tracks on tonsils, sore throat, with negative strep (streptococcal) throat and negative mono (mononucleosis) test results?

White Patches on Tonsils with Negative Strep and Mono Tests

This presentation most likely represents viral pharyngitis, and symptomatic treatment alone is appropriate—antibiotics should be withheld. 1

Diagnostic Interpretation

The negative strep and mono tests effectively rule out the two most common bacterial and atypical causes requiring specific treatment:

• Negative strep test is sufficient in adults to exclude Group A Streptococcal pharyngitis without need for backup throat culture, given the low 5-10% prevalence of GAS in adults and extremely low risk of rheumatic fever 1, 2
• In children and adolescents, a negative rapid strep test should be confirmed with throat culture before finalizing treatment decisions, as rapid tests miss 10-20% of true strep infections in this age group 1
• Negative mono test excludes Epstein-Barr virus infectious mononucleosis, which commonly presents with severe pharyngitis, tonsillar exudate, and white patches 3, 4

Most Likely Diagnosis

Viral pharyngitis is the diagnosis by exclusion and epidemiology:

• Viruses cause the majority of acute pharyngitis cases, including adenovirus, influenza, parainfluenza, rhinovirus, respiratory syncytial virus, coxsackievirus, echoviruses, and herpes simplex virus 3
• White patches and exudate can occur with viral infections and do not reliably distinguish bacterial from viral causes 3
• Up to 70% of patients with sore throats receive unnecessary antibiotics, while only 20-30% actually have GAS pharyngitis 1

Recommended Management

Symptomatic treatment only:

• NSAIDs or acetaminophen for pain and fever relief 1, 2
• Throat lozenges and salt water gargles for temporary symptom relief 2
• Adequate hydration and rest guided by the patient's energy level 4
• Reassurance that symptoms typically resolve in less than 1 week, with most viral pharyngitis resolving in 7-10 days 2

Antibiotics should NOT be prescribed when both strep and mono tests are negative, as treatment would provide no benefit and carries risks of adverse effects and antimicrobial resistance 1, 2

Alternative Diagnoses to Consider

If symptoms persist beyond 1 week or worsen, consider:

• Other viral causes including herpes simplex virus, which can cause pharyngeal ulceration and white patches 3
• Infectious mononucleosis with false-negative heterophile test: False-negative results are relatively common early in the course of EBV infection 4
• Non-infectious causes including gastroesophageal reflux disease, chronic postnasal drip, or allergic/environmental irritants 5
• Fungal infection (candidiasis), particularly if the patient has risk factors such as recent antibiotic use, immunosuppression, or inhaled corticosteroid use 5

When to Reassess

Refer to otolaryngology if symptoms persist beyond 1 month despite appropriate symptomatic therapy for direct visualization and possible tissue sampling 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on appearance alone: White patches and exudate overlap too broadly between bacterial and viral causes to make accurate clinical diagnosis without laboratory confirmation 3
• Do not repeat strep testing unless new symptoms develop or there is documented exposure to confirmed strep pharyngitis 5
• Do not test or treat asymptomatic household contacts prophylactically 1
• Avoid ampicillin/amoxicillin if infectious mononucleosis is still being considered, as these antibiotics cause a characteristic rash in 80-100% of patients with EBV infection 4, 6