What are the likely causes and treatment options for a pediatric patient presenting with sore throat, nasal drainage, fatigue, and ear pain, suggestive of a common viral illness such as adenovirus, respiratory syncytial virus (RSV), or influenza?

Common Pediatric Viruses Causing Sore Throat, Nasal Drainage, Fatigue, and Ear Pain

This clinical presentation is most consistent with a viral upper respiratory infection, with respiratory viruses (rhinovirus, respiratory syncytial virus, adenovirus, parainfluenza, and influenza) being the predominant causes, and treatment should remain supportive unless influenza is confirmed or strongly suspected during flu season. 1

Most Likely Viral Causes

The constellation of sore throat, nasal drainage, fatigue, and ear pain in pediatric patients is typically caused by:

• Rhinovirus - the most common cause of viral upper respiratory infections 1
• Respiratory syncytial virus (RSV) - frequently causes acute pharyngitis and can lead to ear fullness from eustachian tube obstruction 1
• Adenovirus - commonly produces pharyngitis with significant nasal symptoms 1
• Parainfluenza virus - a frequent cause of acute pharyngitis in children 1
• Influenza virus (A and B) - causes systemic symptoms including fatigue, sore throat, and nasal congestion 1

Additional viral causes include coxsackievirus, echoviruses, herpes simplex virus, Epstein-Barr virus (particularly if accompanied by generalized lymphadenopathy and splenomegaly), coronavirus, and enterovirus. 1

Clinical Differentiation: Viral vs. Bacterial

Critical distinction: While viruses cause the majority of acute pharyngitis cases, Group A β-hemolytic streptococcus is the most common bacterial cause and the only one requiring antibiotic therapy to prevent rheumatic fever. 1

Features Strongly Suggesting Viral Etiology:

• Coryza (nasal drainage/rhinorrhea) 1
• Cough 1
• Hoarseness 1
• Conjunctivitis 1
• Diarrhea 1

Features Suggesting Possible Bacterial (Streptococcal) Infection:

• Sudden onset sore throat 1
• Tonsillopharyngeal erythema with or without exudates 1
• Anterior cervical lymphadenitis 1
• Absence of cough 1
• Age 5-15 years 1
• Winter/early spring occurrence 1

Important caveat: Clinical diagnosis alone cannot reliably differentiate streptococcal from viral pharyngitis—even experienced physicians achieve only 35-50% accuracy when all clinical features suggest strep. 1 Therefore, unless obvious viral features (coryza, cough, hoarseness) are present, laboratory testing with rapid antigen detection test (RADT) or throat culture is required. 1

Age-Specific Considerations

Infants and Young Children (<3 years):

• Group A streptococcus is uncommon in preschool children 1
• Rheumatic fever is rare in children younger than 3 years 1
• Viral infections may present with excoriated nares or purulent nasal discharge 1
• RSV bronchiolitis should be considered if lower respiratory symptoms develop 2

School-Age Children (5-15 years):

• Peak age for Group A streptococcal pharyngitis 1
• Higher likelihood of bacterial etiology requiring testing 1

Ear Pain (Otitis Media) Context

Otitis media is the most common bacterial superinfection of influenza, occurring in approximately 25% of patients aged <5 years. 1 Ear fullness can also result from eustachian tube obstruction due to nasal mucosal edema during viral infections. 1

Treatment Approach

For Presumed Viral Infection (with coryza, cough, or other viral features):

Supportive care only:

• Maintain hydration 2
• Fever-reducing medications (avoid aspirin due to Reye's syndrome risk with influenza) 1
• Nasal saline for congestion 1
• Observation for 7-10 days (typical viral course) 1

Do NOT use:

• Antibiotics (no proven benefit for viral pharyngitis) 1
• Bronchodilators, corticosteroids, or chest physiotherapy (not recommended for viral infections) 2

For Confirmed or Suspected Influenza:

Oseltamivir (Tamiflu) should be initiated within 48 hours of symptom onset if:

• Influenza is laboratory-confirmed or strongly suspected during flu season 3
• Patient has fever plus respiratory symptoms (cough, nasal symptoms, sore throat) and systemic symptoms (fatigue, myalgia, chills) 3

Dosing:

• Pediatric patients 1-12 years: weight-based dosing, typically 2 mg/kg twice daily for 5 days 3
• Adolescents ≥13 years: 75 mg twice daily for 5 days 3

Oseltamivir reduces median time to symptom improvement by 1.3-1.5 days compared to placebo. 3

When to Test for Streptococcus:

Perform RADT or throat culture if:

• Absence of viral features (no coryza, cough, or hoarseness) 1
• Age 5-15 years with acute pharyngitis 1
• Tonsillopharyngeal erythema with exudates and anterior cervical lymphadenitis 1

Common Pitfalls to Avoid

1. Over-prescribing antibiotics for viral pharyngitis - contributes to antimicrobial resistance and exposes patients to unnecessary risks without benefit 1

2. Relying solely on clinical diagnosis for streptococcal pharyngitis - accuracy is insufficient; laboratory confirmation is required 1

3. Missing influenza treatment window - oseltamivir must be started within 48 hours of symptom onset for maximal benefit 3

4. Using aspirin in children with viral infections - associated with Reye's syndrome, particularly with influenza 1

5. Routine viral testing - not recommended for clinical management as treatment remains supportive regardless of specific viral etiology 4