What is the best course of treatment for a 21-year-old patient with a persistent sore throat and bilateral knee pain, who works in a role requiring crouching, has bilateral tonsillar swelling without exudate, and anterior knee tenderness, with a history of initial fever and nasal congestion?

Management of Persistent Sore Throat in a 21-Year-Old

Immediate Clinical Decision

This patient requires throat swab testing for Group A Streptococcus before any antibiotic decision, but given the persistent nature (>1 week), viral etiology is most likely and symptomatic treatment should be prioritized. 1, 2

Risk Stratification Using Centor Criteria

Apply the modified Centor criteria to determine testing strategy: 1, 3

• Fever by history: Present initially (1 point)
• Tonsillar exudates: Absent (0 points)
• Tender anterior cervical adenopathy: Mild tenderness noted, but no palpable lymphadenopathy (0 points)
• Absence of cough: Present - patient has nasal congestion but no documented cough (1 point)

Total Score: 2 points 3

With 2 Centor criteria, testing with rapid antigen detection test (RADT) or throat culture is appropriate, which has already been performed (throat swab taken). 1, 3

Critical Red Flag Assessment

The persistence beyond one week with neck swelling requires vigilance for serious complications, particularly in this age group: 2, 3

• Lemierre syndrome consideration: This patient is in the high-risk age group (adolescent/young adult) with persistent pharyngitis and neck tenderness. While no palpable lymphadenopathy was found, the reported "neck swelling" and mild tenderness warrant close monitoring. 1, 3, 4
• No signs of peritonsillar abscess: Absence of severe unilateral pain, trismus, or uvular deviation makes this unlikely. 3
• No airway compromise: No difficulty swallowing, drooling, or respiratory distress. 3

Antibiotic Decision Framework

If Throat Swab Returns POSITIVE for Group A Streptococcus:

Treat with penicillin V 500 mg twice daily for 10 days (or 250 mg three times daily). 1, 5, 6, 7

• Alternative if penicillin-allergic: Azithromycin 500 mg on day 1, then 250 mg daily for days 2-5. 8
• However, counsel the patient that at >1 week duration, antibiotics provide minimal symptom benefit - the primary remaining justification is modest symptom reduction (NNT=21 at one week). 2, 5
• Treatment duration must be 10 days to prevent rheumatic fever, though this complication is extremely rare in developed countries. 1, 5, 6

If Throat Swab Returns NEGATIVE:

Do not prescribe antibiotics. 1, 5, 3

• The persistence beyond typical viral pharyngitis duration (most resolve by 7 days) suggests either a prolonged viral course or the patient may be a chronic GAS carrier with a concurrent viral infection. 1, 2, 5
• Viral pharyngitis with associated nasal congestion is the most likely diagnosis. 1, 3

Symptomatic Management (Regardless of Test Result)

Recommend ibuprofen 400-600 mg every 6-8 hours as needed for pain relief. 2, 5, 7

• NSAIDs provide superior pain relief compared to acetaminophen for pharyngitis. 7
• Reassure that typical sore throat duration is less than one week, but some viral infections persist longer. 2, 5

Management of Bilateral Knee Pain

The bilateral anterior knee pain in this 21-year-old with occupational crouching is consistent with patellofemoral pain syndrome, not related to the pharyngitis.

• The absence of night pain, systemic symptoms, or joint effusion makes septic arthritis or reactive arthritis (post-streptococcal) extremely unlikely.
• This is a separate musculoskeletal issue requiring activity modification, NSAIDs for pain control, and potentially physical therapy referral for strengthening exercises.
• The knee pain is not an indication for antibiotic therapy even if strep throat is confirmed.

Follow-Up Plan

Instruct the patient to return immediately if any of the following develop: 3

• Difficulty swallowing or breathing
• Drooling
• Severe unilateral throat pain
• Persistent high fever with worsening neck pain/swelling (concern for Lemierre syndrome)
• No improvement after 48-72 hours if antibiotics are prescribed

If symptoms persist beyond 2 weeks total, re-evaluation is mandatory to exclude non-infectious causes including malignancy, though this is uncommon in this age group. 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically without microbiological confirmation - clinical features alone cannot distinguish GAS from viral pharyngitis. 3
• Do not dismiss persistent pharyngitis in young adults - maintain high suspicion for Lemierre syndrome, which can be fatal if diagnosis is delayed. 1, 3, 4
• Do not attribute the knee pain to the pharyngitis - these are separate clinical entities requiring distinct management approaches.