How to manage a patient with a sore throat and leukocytosis with neutrophilia?

Management of Sore Throat with Leukocytosis and Neutrophilia

Use the Centor criteria to risk-stratify this patient, then perform a rapid antigen detection test (RADT) or throat culture if 3-4 criteria are present, and treat with penicillin V for 10 days only if Group A streptococcus is confirmed or if high clinical suspicion exists with positive testing. 1

Initial Clinical Assessment

The WBC of 11.86 with 89% neutrophils (absolute neutrophil count ~10.5) indicates bacterial infection is possible but not definitive, as leukocytosis can occur with both viral and bacterial pharyngitis. 2

Apply the modified Centor criteria immediately to determine likelihood of Group A streptococcal infection: 2

• Fever by history (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical adenopathy (1 point)
• Absence of cough (1 point)

Diagnostic Strategy Based on Centor Score

For patients with 0-2 Centor criteria: Do not perform testing and do not prescribe antibiotics, as the likelihood of Group A streptococcus is low and most cases are viral. 1

For patients with 3-4 Centor criteria: Perform rapid antigen detection test (RADT) immediately. 1, 2

• If RADT is positive, treat with antibiotics (no throat culture needed). 1
• If RADT is negative, confirm with throat culture before treating. 1, 3
• RADT has specificity >95% and sensitivity ≥90%, making positive results reliable for immediate treatment decisions. 3

Critical Red Flags Requiring Urgent Evaluation

Before proceeding with routine management, immediately exclude life-threatening complications if the patient has: 2

• Difficulty swallowing or drooling (peritonsillar abscess, epiglottitis)
• Neck tenderness or swelling (parapharyngeal abscess, Lemierre syndrome)
• Airway obstruction symptoms (stridor, respiratory distress)
• Unusually severe presentation despite typical vital signs

These require immediate imaging (CT neck with contrast) and possible ENT/surgical consultation. 2

Treatment Decisions

Symptomatic management for all patients: Ibuprofen or paracetamol for pain relief regardless of etiology. 1

Antibiotic therapy should NOT be used in patients with 0-2 Centor criteria to relieve symptoms. 1 The modest benefits observed in patients with 3-4 Centor criteria must be weighed against side effects, antimicrobial resistance, and costs. 1

If antibiotics are indicated (positive RADT or culture in patient with 3-4 Centor criteria): 1

• Penicillin V 500 mg orally twice daily OR 250 mg three times daily for 10 days 1, 4
• Full 10-day course is mandatory to prevent acute rheumatic fever, even though this complication is rare in Europe. 1, 4
• For penicillin allergy: erythromycin or other macrolide. 5

Important Caveats

Prevention of complications is NOT a primary indication for antibiotics in low-risk patients: 1

• Suppurative complications (quinsy, otitis media, sinusitis) occur rarely and do not justify routine antibiotic use. 1
• Acute rheumatic fever and glomerulonephritis are extremely rare in Europe and should not drive treatment decisions in patients without prior rheumatic fever history. 1

Asymptomatic carriage is common: Up to 20% of school children may carry Group A streptococcus asymptomatically, with carriers having extremely low risk of complications or transmission. 1 This reinforces why clinical scoring and selective testing are essential rather than treating all positive cultures.

Groups C and G streptococci: While these can cause pharyngitis with similar clinical presentation to Group A streptococcus, routine testing and treatment for these organisms is not recommended as their clinical significance remains unclear. 1

Follow-Up Considerations

If symptoms persist beyond 48-72 hours despite appropriate antibiotic therapy: 4

• Consider alternative diagnoses (Epstein-Barr virus, Fusobacterium necrophorum in adolescents/young adults). 2
• Re-evaluate for suppurative complications. 2
• Ensure medication compliance and adequate dosing. 4