What are the next steps for a 27-year-old male with a 5-day history of throat discomfort, cough, and swollen erythematous tonsils, with a past medical history of childhood asthma?

Clinical Assessment and Next Steps

This is most likely viral pharyngitis with reactive tonsillar inflammation, and you should NOT obtain a CBC or other laboratory tests at this point—instead, perform a rapid strep test or throat culture to rule out Group A Streptococcus, and if negative, provide supportive care only. 1

Immediate Diagnostic Approach

Apply the Modified Centor Criteria

Your brother has the following features:

• Swollen erythematous tonsils (present) 1
• Absence of cough (NOT present—he has prominent cough) 1, 2
• Fever by history (not mentioned) 1, 2
• Tender anterior cervical adenopathy (not mentioned) 1, 2

With prominent cough as the primary symptom, this presentation strongly suggests a viral etiology rather than Group A Streptococcus pharyngitis. 1, 2 Cough, particularly when it's the dominant symptom, is more characteristic of viral infections and argues against bacterial pharyngitis. 1, 3

Testing Strategy Based on Clinical Scoring

• Patients with 0-1 Centor criteria should NOT be tested or treated with antibiotics 1, 2
• Patients with 2-3 criteria should undergo rapid antigen detection testing (RADT) 1, 2
• Only treat with antibiotics if RADT is positive 1, 2

Given the prominent cough and lack of clear fever or adenopathy documentation, he likely has ≤1 criterion, making testing optional. However, given the erythematous tonsils, performing a rapid strep test is reasonable to definitively exclude GABHS. 1, 2

Why NOT to Order a CBC or Other Tests

Routine laboratory testing including CBC has no role in the evaluation of uncomplicated pharyngitis in immunocompetent adults. 1, 2 The diagnosis is clinical, supplemented only by rapid strep testing or throat culture when indicated. 1, 2

• Antibiotics have no place in the management of uncomplicated viral respiratory infections or asthma exacerbations 1
• CBC, inflammatory markers, and chest X-rays are not indicated for straightforward pharyngitis presentations 1

Consider Asthma Exacerbation as Contributing Factor

Key Clinical Features Suggesting Asthma Involvement

Your brother has:

• History of childhood asthma 1
• Nocturnal cough predominance (classic for asthma) 1
• Cough triggered by upper respiratory infection 1, 4
• Fluctuating character (dry to productive) 1

Viral respiratory infections are the most common trigger for asthma exacerbations, and cough may be the sole or predominant manifestation of asthma (cough-variant asthma). 1, 4

When to Suspect Active Asthma

• Night-time disturbance by cough is a key clue to asthma diagnosis 1
• Cough precipitated by viral infections strongly suggests asthma 1
• Post-infectious cough lasting beyond 3 weeks suggests bronchial hyperresponsiveness 1

Recommended Management Algorithm

Step 1: Rule Out Bacterial Pharyngitis

• Perform rapid antigen detection test for Group A Streptococcus 1, 2
• If positive: Treat with penicillin or amoxicillin for 10 days 2, 3
• If negative: No antibiotics indicated 1, 2

Step 2: Provide Symptomatic Relief

• Analgesics and antipyretics (acetaminophen or ibuprofen) for throat pain 1, 2
• First-generation antihistamines (diphenhydramine) plus decongestants may help with postnasal drip 1
• Cough suppressants (dextromethorphan) for symptomatic relief 1

Step 3: Assess for Asthma Component

If cough persists beyond 3 weeks or worsens, consider post-infectious bronchial hyperresponsiveness or asthma exacerbation. 1

• Trial of inhaled corticosteroids (ICS) if cough persists >3 weeks with nocturnal predominance 1, 5
• Consider adding short-acting beta-agonist (albuterol) for symptomatic relief if wheezing or dyspnea develops 1, 5
• Peak flow monitoring can help identify variable airflow obstruction 1, 6

Step 4: Red Flags Requiring Urgent Evaluation

• Difficulty swallowing, drooling, neck tenderness, or swelling suggest peritonsillar abscess or deeper space infection 1
• Respiratory distress, inability to complete sentences, or oxygen saturation <92% requires immediate hospital evaluation 5
• Hemoptysis or progressive dyspnea warrants urgent assessment 7

Common Pitfalls to Avoid

Do NOT Order Unnecessary Tests

• CBC and inflammatory markers do not change management in uncomplicated pharyngitis 1
• Chest X-ray is not indicated unless pneumonia is suspected 1
• Throat culture is not needed if RADT sensitivity exceeds 80% 2

Do NOT Prescribe Antibiotics Empirically

• Antibiotics benefit only patients with confirmed GABHS infection 1, 2
• Empiric antibiotics for viral pharyngitis increase adverse events without benefit 1
• The vast majority (85-90%) of adult pharyngitis is viral and self-limited 1, 2

Do NOT Ignore the Asthma History

• Viral infections are the most common trigger for asthma exacerbations 1, 4
• Nocturnal cough in someone with asthma history should prompt consideration of bronchial hyperresponsiveness 1
• Post-infectious cough lasting >3 weeks may respond to inhaled corticosteroids 1

Expected Clinical Course

Most viral pharyngitis resolves within 5-7 days with supportive care alone. 1 If symptoms persist beyond 3 weeks or worsen, reassess for:

• Post-infectious bronchial hyperresponsiveness 1
• Cough-variant asthma or asthma exacerbation 1
• Alternative diagnoses (GERD, postnasal drip, medication-induced cough) 1