What are the next steps for a patient with worsening symptoms of difficulty swallowing, hoarse voice, shortness of breath, and fevers despite being on penicillin (Penicillin) for 48 hours after a strep throat diagnosis?

Immediate Emergency Evaluation Required

This 15-year-old requires immediate emergency department evaluation for possible peritonsillar abscess, retropharyngeal abscess, or epiglottitis—life-threatening complications that can cause airway obstruction and death. The combination of worsening throat pain despite 48 hours of penicillin, difficulty swallowing, hoarse voice, shortness of breath, and persistent fever represents clinical deterioration that demands urgent assessment for suppurative complications 1.

Critical Red Flags Present

• Difficulty swallowing (dysphagia) and hoarse voice suggest deep space infection or airway compromise requiring immediate imaging and possible surgical intervention 1
• Shortness of breath indicates potential airway narrowing from abscess formation or epiglottitis—this is a medical emergency 1
• Clinical worsening after 48 hours of appropriate antibiotic therapy is abnormal, as uncomplicated streptococcal pharyngitis should show improvement within 24-48 hours of penicillin treatment 1
• Persistent fever beyond 48 hours of penicillin therapy suggests either treatment failure, suppurative complication, or incorrect initial diagnosis 1

Immediate Actions in Emergency Department

Airway Assessment First

• Assess airway patency immediately with visualization of the oropharynx and indirect laryngoscopy if safe to perform 1
• Have emergency airway equipment at bedside including intubation supplies and preparation for emergent cricothyrotomy if needed 1
• Do NOT force the patient to lie flat if respiratory distress is present—allow position of comfort to maintain airway 1

Urgent Imaging

• Obtain lateral neck radiograph or CT scan with IV contrast to evaluate for peritonsillar abscess, retropharyngeal abscess, or epiglottitis 1
• CT imaging is preferred as it provides superior visualization of deep space infections and can guide surgical drainage 1

Immediate Broad-Spectrum Antibiotics

• Discontinue oral penicillin and initiate IV antibiotics immediately to cover polymicrobial infection including anaerobes and beta-lactamase producing organisms 1
• Recommended regimen: IV ampicillin-sulbactam or clindamycin to cover Streptococcus pyogenes, oral anaerobes, and Staphylococcus aureus 1
• Alternative: IV ceftriaxone plus metronidazole if beta-lactam allergy is not severe 1

Likely Diagnoses to Consider

Peritonsillar Abscess (Most Common)

• Presents with severe unilateral throat pain, trismus, "hot potato" voice, and uvular deviation away from the affected side 1
• Requires needle aspiration or incision and drainage in addition to IV antibiotics 1
• Failure to drain can lead to airway obstruction, aspiration, or spread to deeper neck spaces 1

Retropharyngeal Abscess

• More common in younger children but can occur in adolescents with severe dysphagia, neck stiffness, and respiratory distress 1
• Requires urgent surgical drainage as medical management alone has high failure rates 1
• Can rapidly progress to mediastinitis or airway obstruction 1

Epiglottitis (Less Common but Life-Threatening)

• Classic presentation includes drooling, dysphagia, respiratory distress, and "tripod" positioning 1
• Do NOT examine the throat with tongue depressor as this can precipitate complete airway obstruction 1
• Requires immediate ENT and anesthesia consultation for controlled intubation in operating room 1

Penicillin Treatment Failure

• Bacteriologic failure rates with penicillin can reach 20-30% due to beta-lactamase producing co-pathogens in the pharynx 1, 2
• However, clinical worsening with new symptoms (dysphagia, dyspnea, hoarse voice) indicates complication rather than simple treatment failure 1

Why This Cannot Wait

• Suppurative complications can progress to airway obstruction within hours requiring emergency surgical airway 1
• Deep space neck infections can spread to mediastinum causing mediastinitis with mortality rates exceeding 40% 1
• Septic thrombophlebitis of internal jugular vein (Lemierre syndrome) can occur with anaerobic infection, leading to septic emboli 1

Common Pitfall to Avoid

Do not simply switch oral antibiotics and send home for outpatient follow-up. The presence of dysphagia, hoarse voice, and shortness of breath mandates immediate evaluation for surgical complications that require drainage, not just different antibiotics 1. While penicillin failure does occur in 20-30% of streptococcal pharyngitis cases 1, 2, the clinical deterioration with new airway symptoms represents a fundamentally different and more dangerous situation requiring emergency intervention 1.