What is the diagnosis and treatment for a 20-year-old female with fever and sore throat for 2 weeks?

Diagnosis and Management of a 20-Year-Old Female with Fever and Sore Throat for 2 Weeks

Primary Diagnosis

This 2-week duration of symptoms exceeds the typical course of both viral and bacterial pharyngitis and requires evaluation for complications, non-infectious causes, or atypical pathogens rather than simple acute pharyngitis. 1

Why This Duration is Atypical

• Most viral pharyngitis resolves within 7 days, even without treatment 1, 2
• Untreated streptococcal pharyngitis shows fever and constitutional symptoms disappearing within 3-4 days, with throat soreness persisting at most 1-2 days longer than antibiotic-treated cases 1, 2
• The ESCMID guideline specifically restricts acute pharyngitis recommendations to symptoms lasting <14 days, explicitly excluding persistent cases from standard diagnostic algorithms 3, 1
• Persistence beyond 2 weeks without other symptoms is atypical and warrants consideration of non-infectious causes 1

Immediate Evaluation Required

Rule Out Life-Threatening Complications First

• Peritonsillar abscess (quinsy): Look for unilateral tonsillar swelling with uvular deviation, trismus, muffled "hot potato" voice 1, 4
• Lemierre syndrome: Particularly important in adolescents and young adults with severe persistent pharyngitis and high fever 3, 1, 2
• Retropharyngeal abscess: Assess for neck stiffness, difficulty swallowing, drooling, neck tenderness or swelling 1, 4
• Epiglottitis: Though rare, presents with difficulty swallowing, drooling, and respiratory distress 5, 4

Consider Non-Infectious Etiologies

• Gastroesophageal reflux disease: Can present as chronic throat irritation mimicking pharyngitis 1
• Neoplastic processes: Must be considered in persistent symptoms, especially in young adults 1, 2
• Thyroiditis: Uncommon but can present as sore throat 5

Diagnostic Approach

If No Red Flags Present, Proceed with Testing

Obtain throat culture or rapid antigen detection test (RADT) for Group A Streptococcus, even though the prolonged duration makes this diagnosis less likely 3

• If RADT is positive, this confirms streptococcal pharyngitis, though the patient may be a chronic carrier with concurrent viral illness 3, 6
• If RADT is negative in this age group, throat culture backup is generally not necessary in adults due to low incidence and low risk of rheumatic fever 3

Laboratory Interpretation Caveats

Do not rely solely on complete blood count to differentiate bacterial from viral causes 6

• Bacterial pharyngitis typically shows WBC >12,000/mm³ with neutrophilia and left shift 6
• Viral pharyngitis typically shows WBC <10,000/mm³ with relative lymphocytosis 6
• However, these findings have poor sensitivity and specificity and cannot replace microbiological confirmation 6

Consider Atypical Pathogens

• Epstein-Barr virus (infectious mononucleosis): Look for generalized lymphadenopathy, splenomegaly, and atypical lymphocytes on blood smear 5
• Fusobacterium necrophorum: Implicated in 10-20% of endemic pharyngitis in adolescents and can lead to Lemierre syndrome 3
• Mycoplasma pneumoniae or Chlamydia pneumoniae: Consider if associated atypical pneumonia symptoms present 3, 5

Treatment Recommendations

If Group A Streptococcus is Confirmed

Penicillin V 500 mg twice or three times daily for 10 days remains first-line treatment 3, 1, 6

• Alternative: Amoxicillin 500 mg twice daily for 10 days 3, 7
• For penicillin allergy: First-generation cephalosporin, clindamycin 20 mg/kg/day divided three times daily (max 1.8 g/day), azithromycin 500 mg once daily for 5 days, or clarithromycin 250 mg twice daily for 10 days 3

Critical caveat: At 2 weeks duration, antibiotic benefit for symptom reduction is negligible, as the natural course has already exceeded the 1-2 day benefit window that antibiotics provide 1

Symptomatic Management Regardless of Etiology

Ibuprofen or acetaminophen for pain relief 3, 1

• Aspirin, acetaminophen, NSAIDs, and throat lozenges all provide effective analgesia 3
• Avoid aspirin in children due to Reye syndrome risk 3
• Zinc gluconate is not recommended 3

If Testing is Negative or Patient Appears Toxic

Refer for direct laryngoscopy to visualize the pharynx and larynx 2

• Transnasal flexible fiberoptic laryngoscopy is the standard office procedure 2
• Delays in diagnosis beyond 3 months lead to higher disease stage and worse prognosis for laryngeal malignancies 2

Common Pitfalls to Avoid

• Do not assume this is simple streptococcal pharyngitis and prescribe antibiotics empirically—the 2-week duration makes this diagnosis unlikely 1
• Do not apply Centor or FeverPAIN scores to this case—these tools are validated only for acute presentations (<14 days) and have poor diagnostic accuracy even in appropriate populations 3, 1, 8
• Do not dismiss the patient with reassurance alone—absence of other symptoms does not rule out serious pathology in a 2-week presentation 1
• Do not continue prescribing antibiotics without proper evaluation, as over 60% of adults with sore throat receive unnecessary antibiotics 3, 2
• Do not wait for 3 months before seeking specialist evaluation—a 1-month duration already exceeds typical viral illness and warrants earlier assessment 2

Specific Algorithm for This Patient

1. Perform focused physical examination looking for unilateral swelling, uvular deviation, trismus, neck masses, or signs of systemic toxicity 1, 4
2. If any red flags present, arrange urgent ENT evaluation or emergency department referral 1, 4
3. If no red flags, obtain throat culture or RADT 3
4. If positive for Group A Streptococcus, treat with penicillin V or amoxicillin for 10 days, but counsel that symptom benefit will be minimal at this stage 1, 7
5. If negative, consider laryngoscopy referral given the atypical duration, especially if symptoms persist beyond 3 weeks total 2
6. Provide symptomatic relief with NSAIDs or acetaminophen regardless of etiology 3, 1