Diagnosis and Treatment of Acute Pharyngitis with Systemic Symptoms
Most Likely Diagnosis
This patient most likely has Group A Streptococcal (GAS) pharyngitis requiring microbiological confirmation before treatment. The combination of sore throat, night sweats, chills, headache, and ear congestion without cough or rhinorrhea strongly suggests bacterial rather than viral pharyngitis 1.
Clinical Reasoning
The presence of night sweats is a suspicious symptom for bacterial pharyngitis that should prompt testing for Group A Streptococcus, particularly when accompanied by persistent fever, rigors, and other systemic symptoms 1. This patient's symptom constellation—sore throat, chills/sweats, headache with ear involvement, and notably the absence of cough—aligns with bacterial pharyngitis rather than viral upper respiratory infection 2, 1.
Key Distinguishing Features Present:
- Night sweats and chills (systemic inflammatory response suggesting bacterial infection) 1
- Sore throat as primary complaint 2
- Ear involvement (likely referred pain from pharyngeal inflammation or associated Eustachian tube dysfunction) 3
- Absence of cough (viral pharyngitis typically presents with cough, rhinorrhea, and other respiratory symptoms) 2, 1
Features Arguing Against Viral Etiology:
- No rhinorrhea (viral infections typically cause runny nose) 2, 1
- No cough (absence of cough increases likelihood of bacterial pharyngitis) 1, 4
- Systemic symptoms (night sweats, chills) suggest bacterial infection 1
Mandatory Diagnostic Testing
Do NOT treat empirically with antibiotics. Microbiological confirmation is mandatory before treating suspected bacterial pharyngitis 2, 1.
Testing Strategy:
- Perform rapid antigen detection test (RADT) for Group A Streptococcus 2, 1
- If RADT is negative, obtain throat culture (RADT has high specificity but lower sensitivity) 2, 4
- Treat with antibiotics ONLY if testing confirms streptococcal pharyngitis 2, 1
The American College of Physicians and CDC explicitly state that clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis and treat with antibiotics only if they have confirmed streptococcal pharyngitis 2.
Treatment Algorithm
If Testing Confirms GAS Pharyngitis:
First-line antibiotic: Amoxicillin 5
- Amoxicillin is indicated for upper respiratory tract infections of the ear, nose, and throat due to susceptible Streptococcus species 5
- Should be taken at the start of a meal to minimize gastrointestinal intolerance 5
- Continue treatment for minimum 48-72 hours beyond symptom resolution 5
Symptomatic Management (Regardless of Test Results):
Provide analgesic therapy immediately 2:
- Aspirin, acetaminophen, or NSAIDs 2
- Throat lozenges 2
- Salt water gargles (though limited data supports this) 2
If Testing is Negative for GAS:
Reassure the patient that typical sore throat resolves in less than 1 week and antibiotics are not needed because they do little to alleviate symptoms and may have adverse effects 2.
Critical Pitfalls to Avoid
Do not treat empirically without testing - Clinical features alone, even with night sweats, cannot reliably differentiate bacterial from viral causes 1
Do not test patients with obvious viral features - If the patient had cough, rhinorrhea, conjunctivitis, or hoarseness, testing would not be indicated 1
Do not assume ear congestion requires separate treatment - Ear fullness/congestion is commonly referred pain from pharyngeal inflammation and typically resolves with treatment of the primary pharyngitis 3
Do not order imaging - Chest X-ray or sinus imaging is not indicated for uncomplicated pharyngitis 2
When to Consider Alternative Diagnoses
Red flags requiring broader evaluation 3:
- Fever with constitutional symptoms persisting beyond 1 week
- Weight loss
- Severe dysphagia preventing oral intake
- Respiratory distress or stridor
- Unilateral tonsillar swelling (consider peritonsillar abscess)
If these features are present, assume you may have missed the diagnosis and pursue further evaluation 3.