What is the diagnosis and next steps for a 24-year-old female with sore throat, odynophagia, fever, and dry cough, prescribed celecoxib, with absent lymphadenopathy and normal otoscopy?

Diagnosis and Management of Acute Pharyngitis in a 24-Year-Old Female

This patient most likely has viral pharyngitis and does not require antibiotics or further testing at this time, but requires a thorough oropharyngeal examination to confirm the absence of bacterial features and rule out serious complications.

Clinical Assessment Using Modified Centor Criteria

The modified Centor criteria should guide your diagnostic approach. This patient scores 2 out of 4 points: 1, 2

• Fever by history: Present (38-38.8°C) = 1 point
• Tonsillar exudates: Not documented in PE = 0 points
• Tender anterior cervical adenopathy: Absent per PE = 0 points
• Absence of cough: No, dry cough present = 0 points

With a Centor score of 2, the probability of Group A Streptococcus (GAS) is low (approximately 15%), but testing with rapid antigen detection test (RADT) should be considered. 1, 2

Critical Red Flags to Evaluate Immediately

You must perform a complete oropharyngeal examination to look for:

• Tonsillar exudates, erythema, or swelling - not adequately documented in your initial PE 1
• Palatal petechiae or uvular edema - suggests bacterial infection 1, 3
• Peritonsillar fullness or asymmetry - suggests abscess 1
• Severe odynophagia with drooling or neck swelling - suggests deep space infection 1

Given this patient's age (24 years) and severe persistent pharyngitis, you must remain vigilant for Lemierre syndrome, a rare but life-threatening complication of pharyngitis in adolescents and young adults. 1 Warning signs include neck tenderness, swelling, or persistent high fever despite treatment.

Viral vs. Bacterial Differentiation

The presence of dry cough strongly suggests viral etiology. 1, 3 Additional viral features to assess include:

• Rhinorrhea, nasal congestion 1, 3
• Conjunctivitis 1
• Hoarseness 1
• Oral ulcers or vesicles 1, 3

Most pharyngitis cases (70-85% in adults) are viral, caused by rhinovirus, coronavirus, adenovirus, influenza, or Epstein-Barr virus. 2, 3

Diagnostic Testing Recommendation

If your complete oropharyngeal examination reveals tonsillar exudates or other bacterial features, perform RADT for GAS. 1, 2 However, if the examination confirms only erythema without exudates and the patient has cough, no testing is needed and antibiotics should not be prescribed. 1

Do not rely on complete blood count to differentiate viral from bacterial pharyngitis, as laboratory values have poor sensitivity and specificity for this purpose. 3

Management Plan

Immediate Next Steps:

1. Complete oropharyngeal examination documenting presence/absence of exudates, tonsillar size, uvular appearance, and palatal petechiae 1, 3

2. Palpate for true anterior cervical lymphadenopathy (not just post-auricular tenderness) 1

3. If ≥3 Centor criteria or concerning bacterial features present: Perform RADT 1, 2

4. If viral features predominate (cough present, no exudates): No testing needed 1

Treatment Modifications:

Discontinue celecoxib and switch to more appropriate symptomatic therapy. While celecoxib has demonstrated efficacy for pharyngitis pain, 4, 5 it is not first-line therapy.

Recommended symptomatic treatment includes: 1, 2, 6

• NSAIDs (ibuprofen) or acetaminophen for pain and fever - more effective than acetaminophen alone 6
• Medicated throat lozenges every 2 hours 6
• Adequate hydration 3
• Warm saline gargles 3

If GAS is confirmed by positive RADT, treat with: 1, 2

• Penicillin V 500 mg orally 2-3 times daily for 10 days, OR
• Amoxicillin 500 mg twice daily for 10 days

Common Pitfalls to Avoid

Do not prescribe antibiotics based on symptom severity or duration alone without microbiological confirmation. 1 Even with severe symptoms, only 35-50% of clinically suspected cases are GAS-positive. 3

Do not assume the patient needs antibiotics because symptoms persisted for one week. Viral pharyngitis can last 7-10 days. 1

If you suspect infectious mononucleosis (EBV) based on generalized lymphadenopathy, posterior cervical nodes, or significant fatigue, never prescribe amoxicillin or ampicillin due to risk of severe maculopapular rash. 2

The patient's occupational voice use (frequent talking) explains symptom exacerbation but does not change the underlying viral vs. bacterial determination. 1