What is the recommended treatment for a healthy adult with symptoms of fatigue, rhinorrhea, and pharyngitis, considering a possible history of allergies?

Treatment for Fatigue, Running Nose, and Sore Throat

For a healthy adult with fatigue, rhinorrhea, and sore throat, symptomatic treatment with analgesics (acetaminophen, NSAIDs, or throat lozenges) is recommended, as these symptoms most likely represent a viral upper respiratory infection that will resolve within one week without antibiotics. 1

Initial Assessment and Likely Diagnosis

• These symptoms—fatigue, rhinorrhea (running nose), and pharyngitis (sore throat)—are consistent with a viral upper respiratory infection, which is self-limited and resolves within 7 days in most cases 1
• The presence of fatigue alongside nasal symptoms may indicate nasal congestion causing sleep disturbance and subsequent daytime fatigue, which is common in both viral rhinitis and allergic rhinitis 2
• Antibiotics should NOT be prescribed unless there is confirmed group A streptococcal pharyngitis, as viral infections do not respond to antibiotics and inappropriate use contributes to antimicrobial resistance 1

When to Test for Streptococcal Pharyngitis

• Test for group A Streptococcus only if the patient has symptoms suggestive of bacterial pharyngitis: persistent fever, anterior cervical adenitis (swollen lymph nodes in front of neck), and tonsillopharyngeal exudates (white patches on tonsils) 1
• Use rapid antigen detection test and/or throat culture before prescribing antibiotics 1
• If streptococcal pharyngitis is confirmed, antibiotics shorten symptom duration by only 1-2 days, with a number needed to treat of 6 after 3 days 1

Symptomatic Treatment Recommendations

For sore throat:

• Offer analgesic therapy including aspirin, acetaminophen, NSAIDs, or throat lozenges to reduce pain 1
• Salt water gargles and viscous lidocaine are commonly used but have limited evidence supporting their efficacy 1

For rhinorrhea (running nose):

• If symptoms suggest allergic rhinitis (nasal itching, sneezing, eye symptoms), consider second-generation oral antihistamines (cetirizine, fexofenadine, loratadine, desloratadine) for mild intermittent symptoms 3, 4
• Intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) are first-line therapy if symptoms are moderate to severe or persistent, as they are the most effective treatment for controlling nasal symptoms 3, 5, 6
• Nasal saline irrigation provides adjunctive relief by facilitating clearance of nasal secretions 3, 5

For fatigue:

• Fatigue may be secondary to nasal congestion causing sleep fragmentation and microarousals during sleep 2
• Treating nasal congestion with intranasal corticosteroids can significantly improve sleep quality and reduce daytime fatigue 2

Distinguishing Allergic from Viral Rhinitis

• Allergic rhinitis is characterized by nasal itching, sneezing, and eye symptoms (itchy, watery eyes), which are typically absent in viral infections 3, 4
• Viral rhinitis typically includes sore throat, general malaise, and resolves within 7-10 days 1, 7
• If allergic rhinitis is suspected based on history (seasonal pattern, exposure to allergens, family history of allergies), initiate treatment with intranasal corticosteroids or second-generation antihistamines 3, 5, 6

Critical Medications to AVOID

• Never use first-generation antihistamines (diphenhydramine, chlorpheniramine) due to sedation, anticholinergic effects, and impaired work performance 5, 6
• Limit topical nasal decongestants (oxymetazoline, phenylephrine) to 3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion) 3, 5, 6
• Avoid oral or systemic corticosteroids for routine management, as they have significant adverse effects and are contraindicated for chronic use 5, 6
• Do not prescribe antibiotics empirically without confirmed bacterial infection, as they provide minimal benefit for viral infections and may cause adverse effects 1

When to Reassess or Refer

• If symptoms persist beyond 10 days without improvement, consider acute bacterial rhinosinusitis and reassess for bacterial infection 1
• If symptoms worsen after initial improvement ("double worsening"), this suggests possible bacterial superinfection requiring further evaluation 1
• If symptoms are inadequately controlled with over-the-counter treatments, or if there are complications such as severe facial pain, high fever (>39°C), or purulent nasal discharge lasting >3 consecutive days, further evaluation is warranted 1