What is the diagnosis and treatment for a patient with a sore throat, odynophagia, and mild fever, who complains of pain when swallowing?

Acute Pharyngitis: Diagnosis and Management

Immediate Clinical Assessment

This patient most likely has acute pharyngitis, which is viral in 65-85% of cases, but Group A β-hemolytic streptococcus (GABHS) must be ruled out through microbiological testing before initiating treatment. 1

The presenting symptoms—sore throat, odynophagia (painful swallowing), and mild fever—are consistent with both viral and bacterial pharyngitis, making clinical differentiation impossible without laboratory confirmation. 1

Diagnostic Approach

Clinical Features to Assess

Examine for features suggesting GABHS pharyngitis: 1, 2

• Tonsillopharyngeal erythema with or without exudates
• Tender, enlarged anterior cervical lymph nodes
• Palatal petechiae ("doughnut lesions")
• Beefy red, swollen uvula
• Sudden onset of symptoms
• Absence of viral features (see below)

Examine for features suggesting viral etiology: 1, 2

• Cough
• Coryza (runny nose)
• Hoarseness
• Conjunctivitis
• Diarrhea
• Characteristic viral rash

Critical caveat: Even experienced clinicians cannot reliably distinguish GABHS from viral pharyngitis based on clinical findings alone—none of these features, individually or collectively, is specific enough for definitive diagnosis. 1, 2

Mandatory Laboratory Testing

Microbiological confirmation with either throat culture or rapid antigen detection test (RADT) is required when GABHS is suspected. 1

• Perform RADT or throat culture if the patient has 2-4 clinical features suggestive of GABHS (sudden-onset sore throat, fever, tonsillar findings, tender anterior cervical nodes, absence of cough). 1, 3
• Do NOT test patients with prominent viral symptoms (cough, coryza, conjunctivitis, hoarseness), as this identifies carriers rather than true infections. 4
• Throat culture is the gold standard; RADT provides rapid results but may require culture backup if negative in children. 1

Treatment Strategy

Symptomatic Management (All Patients)

Ibuprofen or paracetamol (acetaminophen) are recommended for symptom relief and are the most effective treatments available. 1, 5, 3

• NSAIDs are more effective than acetaminophen for fever and pain relief. 3
• Medicated throat lozenges used every two hours provide additional relief. 3
• Zinc gluconate is not recommended. 1, 5

Antibiotic Therapy (GABHS-Positive Patients Only)

If GABHS is confirmed by testing, penicillin V is the first-line antibiotic: 250 mg twice or three times daily for 10 days. 1, 5, 6

Alternative first-line option: 7, 4, 3

• Amoxicillin 500 mg every 12 hours or 250 mg every 8 hours for 10 days (adults)
• Amoxicillin may improve compliance due to better taste and tolerability

For penicillin-allergic patients: 3

• First-generation cephalosporins
• Clindamycin
• Macrolide antibiotics (though resistance is increasing)

Treatment duration must be 10 days to prevent acute rheumatic fever. 7, 6

When NOT to Prescribe Antibiotics

Do not prescribe antibiotics if: 1, 5, 4

• RADT or throat culture is negative
• Patient has prominent viral symptoms (cough, coryza, conjunctivitis)
• Testing was not performed and clinical suspicion is low (0-2 clinical features)

The modest benefits of antibiotics in confirmed GABHS must be weighed against side effects, antimicrobial resistance, and costs. 1, 5 Antibiotics are not needed to prevent suppurative complications in most patients. 1, 5

Common Pitfalls to Avoid

• Never diagnose GABHS based on clinical findings alone—up to 70% of sore throat patients receive unnecessary antibiotics because physicians overestimate the probability of bacterial infection. 5, 8
• Do not test asymptomatic contacts of GABHS patients, as this identifies carriers. 4
• Do not use fever presence or absence as a diagnostic criterion—fever varies in GABHS and is not specific enough for diagnosis. 9
• Do not prescribe shorter antibiotic courses—10 days is required to prevent rheumatic fever. 1, 7, 6

Patient Education

Inform patients that: 5

• Most sore throats are viral and self-limiting within 7 days
• Antibiotics do not help viral pharyngitis
• Symptomatic treatment with ibuprofen or acetaminophen is appropriate while awaiting test results
• Seek immediate care for severe difficulty swallowing or breathing