What could be causing a 4-day sore throat with no fever or systemic symptoms, worsened by laying down, in a patient with two negative streptococcal (strep) tests and a negative COVID-19 and influenza test?

Likely Diagnosis: Gastroesophageal Reflux Disease (GERD) or Laryngopharyngeal Reflux (LPR)

Your sore throat that worsens when lying down, with no fever or systemic symptoms and negative infectious testing, is most likely caused by acid reflux affecting your throat rather than an infection.

Why This Is Not Strep or Viral Pharyngitis

• Two negative strep tests effectively rule out Group A streptococcal pharyngitis, as rapid antigen detection tests have >95% specificity 1
• Negative COVID-19 and influenza tests exclude these common viral causes 1
• The absence of fever, systemic symptoms, and the 4-day duration without worsening make typical viral pharyngitis less likely, as viral sore throats usually present with cough, rhinorrhea, or other upper respiratory symptoms 1
• Your Centor score appears to be 0-1 (no fever, presumably no exudates, no tender lymph nodes, no mention of these findings), which corresponds to only a 1-10% probability of streptococcal infection 2

The Key Clue: Worse When Lying Down

• Sore throat that specifically worsens when lying down is a classic presentation of gastroesophageal reflux or laryngopharyngeal reflux, where stomach acid irritates the throat and larynx
• This positional worsening occurs because gravity no longer helps keep stomach contents down when you're horizontal
• Unlike infectious pharyngitis, reflux-related throat irritation typically lacks fever, lymphadenopathy, or systemic symptoms

Critical Questions to Refine This Diagnosis

Reflux-Related Questions:

• Do you have heartburn, regurgitation, or a sour taste in your mouth? [@general medical knowledge@]
• Does the throat pain worsen after meals or at night? [@general medical knowledge@]
• Do you have a sensation of a lump in your throat or frequent throat clearing? [@general medical knowledge@]
• Have you noticed hoarseness or voice changes? [@general medical knowledge@]

Alternative Diagnosis Questions:

• Do you have postnasal drip or chronic nasal congestion that might drain down your throat when lying down? [@general medical knowledge@]
• Are you a mouth breather at night, which could cause throat dryness and irritation? [@general medical knowledge@]
• Do you have any difficulty swallowing, drooling, or neck swelling that might suggest a more serious condition like peritonsillar abscess? 1
• Any recent exposure to irritants like smoke, chemicals, or allergens? [@general medical knowledge@]

Recommended Management Approach

Symptomatic Treatment (Appropriate for All Causes):

• Use ibuprofen or acetaminophen for throat pain relief 1
• This is appropriate regardless of the underlying cause and provides effective symptom control 1

If Reflux Is Suspected:

• Elevate the head of your bed 6-8 inches [@general medical knowledge@]
• Avoid eating 2-3 hours before bedtime [@general medical knowledge@]
• Consider a trial of over-the-counter proton pump inhibitor (omeprazole 20mg daily) for 2-4 weeks [@general medical knowledge@]
• Avoid trigger foods (caffeine, alcohol, spicy foods, chocolate, mint) [@general medical knowledge@]

When to Seek Urgent Evaluation:

• Development of difficulty swallowing, drooling, or severe neck pain/swelling suggests peritonsillar abscess or other serious complications requiring immediate assessment 1
• Persistent symptoms beyond 2 weeks warrant re-evaluation for other causes 1

Why Antibiotics Are Not Indicated

• Antibiotics should not be prescribed for your presentation, as you have 0-2 Centor criteria with negative testing, making bacterial infection extremely unlikely 1
• Even if strep were present, antibiotics only shorten symptom duration by 1-2 days and carry risks of side effects and antibiotic resistance 3, 2
• The prevention of complications like rheumatic fever is not a justification for empiric antibiotics in low-risk patients like yourself 4