What is the initial management for a patient presenting with a unilateral painful swollen lymph node and sore throat?

Initial Management of Unilateral Painful Swollen Lymph Node with Sore Throat

Begin with symptomatic treatment using ibuprofen or paracetamol for pain relief, then apply the Centor criteria to determine if antibiotics are warranted—reserving antibiotics only for patients with 3-4 Centor criteria after microbiological confirmation. 1

Immediate Assessment Using Centor Criteria

Apply the Centor scoring system to risk-stratify for Group A streptococcal (GAS) pharyngitis 1:

• Fever (1 point)
• Absence of cough (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical lymphadenopathy (1 point) 2

The unilateral painful lymph node presentation you describe counts toward this scoring system 3, 2.

Critical Red Flags Requiring Urgent Evaluation

Before proceeding with routine management, immediately assess for suppurative complications 2:

• Peritonsillar abscess (quinsy): Look for severe unilateral throat pain, trismus, uvular deviation away from the affected side, and "hot potato voice" 2
• Deep space neck infection: Assess for neck swelling, difficulty breathing, or systemic toxicity 4
• Lemierre's syndrome: Consider if persistent fever with neck pain develops 2

If any of these features are present, this requires urgent ENT consultation and imaging (CT neck), not outpatient management. 4

Symptomatic Treatment (All Patients)

Initiate analgesic therapy immediately regardless of Centor score 1:

• Either ibuprofen or paracetamol for symptom relief (A-1 evidence) 1
• Encourage adequate hydration with cool liquids 2

This symptomatic approach is appropriate while determining if antibiotics are needed 1.

Antibiotic Decision Algorithm Based on Centor Score

Score 0-2: No Antibiotics Indicated

Do not prescribe antibiotics for patients with 0-2 Centor criteria 1:

• Antibiotics provide no meaningful benefit in symptom relief for this group (A-1 evidence) 1
• The presentation is likely viral, and antibiotics increase resistance without improving outcomes 1
• Continue symptomatic treatment only 2

Score 3-4: Consider Testing and Antibiotics

For patients with 3-4 Centor criteria, perform microbiological confirmation before prescribing antibiotics 5, 2:

• Rapid antigen detection test (RADT) is the preferred initial test 1, 5
• Clinical features alone cannot reliably distinguish GAS from viral pharyngitis—microbiological confirmation is mandatory 5, 2
• In children and adolescents, a negative RADT must be backed up by throat culture 5
• In adults, negative RADT alone is sufficient without culture confirmation 5

If GAS is confirmed, prescribe penicillin V twice or three times daily for 10 days 1:

• Penicillin V remains first-line due to proven efficacy, narrow spectrum, safety, and low cost 1
• GAS has shown no resistance to penicillin over five decades 1
• For penicillin-allergic patients: use first-generation cephalosporin, clindamycin, clarithromycin, or azithromycin 5

Important Clinical Nuances

The unilateral presentation does not automatically indicate bacterial infection 3:

• Tender, enlarged anterior cervical lymph nodes are strongly associated with streptococcal infection, but identical findings occur with viral infections 3
• Visual findings alone predict positive cultures only 80% of the time at best 3

Delayed prescribing is a valid option 1:

• No significant differences in complication rates between immediate antibiotics, delayed antibiotics (>48 hours), or no antibiotics 1
• This approach reduces unnecessary antibiotic use while maintaining safety 1

When Antibiotics Are Prescribed: Expected Benefits

Counsel patients that antibiotic benefits are modest 1:

• Antibiotics hasten symptom improvement by only 1-2 days in GAS-positive patients 1
• These modest benefits must be weighed against side effects, effects on microbiota, increased antimicrobial resistance, and costs 1
• Antibiotics reduce symptoms on day 3, but by 1 week, only GAS-positive patients show benefit over placebo 1

Common Pitfalls to Avoid

Do not prescribe antibiotics to prevent suppurative complications in routine cases 1:

• The number needed to treat to prevent one case of quinsy is 27 or higher 1
• In modern primary care settings, the number needed to treat is between 50-200 1
• Prevention of suppurative complications is not a specific indication for antibiotic therapy (A-1 evidence) 1

Do not prescribe antibiotics to prevent rheumatic fever in low-risk patients 1:

• The absolute risk of rheumatic fever is extremely small in the Western world 1
• Antibiotic treatment to prevent non-suppurative complications is only justified in high-risk patients (those with previous rheumatic fever) 1

Do not routinely use corticosteroids 1:

• Corticosteroids in conjunction with antibiotics are not routinely recommended 1
• Can be considered only in adult patients with severe presentations (3-4 Centor criteria) 1

Alternative Diagnoses to Consider

If GAS testing is negative but symptoms persist, consider 5, 2:

• Epstein-Barr virus (infectious mononucleosis): Look for posterior cervical adenopathy and splenomegaly 2
• Arcanobacterium haemolyticum: Particularly in teenagers and young adults 5
• Groups C and G β-hemolytic streptococci: Can cause similar presentations with milder symptoms 2