What is the diagnosis and treatment for a patient presenting with a dry cough, throat pain, mild exudate on mildly swollen tonsils, and a dark patch above the tonsils?

Diagnosis and Management of Pharyngotonsillitis with Concerning Features

This presentation requires immediate evaluation for Group A Streptococcus (GAS) pharyngitis using a validated clinical scoring system, followed by rapid antigen detection testing or throat culture if indicated, with the "dark patch above tonsils" necessitating urgent assessment to rule out peritonsillar abscess or other serious complications. 1, 2

Immediate Diagnostic Approach

Clinical Scoring for GAS Probability

The presence of throat pain, tonsillar exudate, and swollen tonsils warrants systematic evaluation using the Centor or McIsaac scoring criteria to estimate bacterial infection probability before testing decisions 1, 2:

• Fever >38.5°C (1 point)
• Tonsillar exudate or swelling (1 point) - present in this case
• Tender anterior cervical lymphadenopathy (1 point)
• Absence of cough (1 point) - CRITICAL: This patient has a dry cough, which significantly reduces GAS probability 1, 3

The presence of cough strongly suggests viral etiology rather than streptococcal infection 1, 3, 4. Cough, along with coryza, conjunctivitis, and diarrhea are uncommon in GAS pharyngitis and their presence points toward viral causes 3.

Urgent Concern: The "Dark Patch"

The dark patch above the tonsils requires immediate visual inspection and clinical correlation 2. This finding could represent:

• Peritonsillar abscess - requires urgent drainage and IV antibiotics 2
• Necrotic tissue - may indicate severe infection or diphtheria (though rare) 1
• Hemorrhagic lesion - needs urgent evaluation 2

If the dark patch represents fluctuance, asymmetric tonsillar displacement, or uvular deviation, immediate referral to ENT or emergency department is mandatory 2.

Testing Strategy

When to Test for GAS

Only test if at least 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, absence of cough 1.

Given this patient has cough (which argues against GAS), testing may not be indicated unless other high-risk features are present 1. However, the mild exudate and tonsillar swelling warrant consideration of testing if clinical suspicion remains 1, 2.

Testing Method

• Rapid antigen detection test (RADT) provides results within minutes and should be the first-line diagnostic tool 3
• Throat culture remains the gold standard if RADT is negative but clinical suspicion persists, though results take 1-2 days 3
• Do NOT treat empirically without confirmation - this leads to antibiotic overuse 1

Treatment Algorithm

If GAS is Confirmed

First-line antibiotic: Penicillin or Amoxicillin for 10 days 1, 2, 3:

• Penicillin V: 250-500mg orally 2-3 times daily for 10 days 1, 3
• Amoxicillin: 500mg twice daily or 1000mg once daily for 10 days (better compliance) 1, 2

For penicillin allergy:

• First-generation cephalosporins (if no severe penicillin allergy) 3
• Macrolides (azithromycin or clarithromycin) only if true penicillin allergy 3

Critical: Complete the full 10-day course to prevent rheumatic fever and post-streptococcal glomerulonephritis 1, 2, 3.

If Viral Etiology (Most Likely Given Cough)

Supportive care only - antibiotics provide no benefit and cause harm 1, 2, 5:

• Analgesia: Combination of acetaminophen/paracetamol AND NSAIDs (ibuprofen) provides superior pain relief 6
• Hydration: Adequate fluid intake 5
• Symptomatic relief: Throat lozenges, warm salt water gargles 5
• Expected duration: 3-7 days for viral pharyngitis 2, 5

Management of the Dry Cough

The dry cough component requires separate evaluation as it may represent a distinct or overlapping process 1, 7:

If Cough Persists Beyond Pharyngitis Resolution

• Consider post-infectious cough if lasting 3-8 weeks after acute infection 1, 8
• First-line treatment: Inhaled ipratropium bromide 2-3 puffs four times daily 7, 8
• Avoid antibiotics for post-viral cough - they provide no benefit 1, 8

If Paroxysmal Cough with Post-Tussive Vomiting

Pertussis must be ruled out, even in vaccinated patients 1, 7:

• Obtain nasopharyngeal culture or PCR 1
• If confirmed: Macrolide antibiotic (azithromycin 500mg day 1, then 250mg days 2-5) 1
• Isolate patient for 5 days from treatment start 1

Critical Pitfalls to Avoid

Do not prescribe antibiotics without confirmed bacterial infection - this increases antibiotic resistance, causes adverse effects including C. difficile colitis, and provides no clinical benefit for viral infections 1, 7, 6.

Do not ignore the "dark patch" - failure to identify and treat peritonsillar abscess can lead to airway compromise, sepsis, and death 2.

Do not assume absence of fever rules out serious pathology - the dark patch finding overrides typical clinical scoring and requires direct visualization 2.

Do not use azithromycin or third-generation cephalosporins as first-line for GAS - S. pneumoniae resistance makes these poor choices 1.

Follow-Up Recommendations

• Re-evaluate in 48-72 hours if symptoms worsen or new symptoms develop 2, 6
• Return immediately if difficulty breathing, drooling, severe unilateral throat pain, or inability to swallow 2
• If cough persists beyond 8 weeks, reclassify as chronic cough and evaluate for asthma, GERD, or upper airway cough syndrome 1, 8