SARS-CoV-2 Cannot Explain a 5-Year History of Chronic Pharyngitis
SARS-CoV-2 did not exist until late 2019 and therefore cannot be the cause of pharyngitis that began 5 years ago in this 18-year-old patient. 1, 2 The timeline is biologically impossible—this patient's symptoms predate the emergence of the virus by approximately 2-3 years.
Critical Timeline Analysis
- SARS-CoV-2 emerged in Wuhan, China in late 2019, with the first cases identified at the end of that year 2
- The WHO declared COVID-19 a public health emergency on January 30,2020 2
- A 5-year history of sore throat in an 18-year-old means symptoms began around age 13, which would be approximately 2017-2018—well before SARS-CoV-2 existed 1, 2
What About "Long COVID" Pharyngitis?
While COVID-19 can cause acute pharyngitis with an incidence of 5-17.4% during active infection 3, there is no evidence in the provided literature supporting chronic pharyngitis as a manifestation of post-COVID syndrome or "long COVID." The acute pharyngitis associated with SARS-CoV-2 is a symptom of active infection, not a chronic inflammatory condition 3.
Alternative Diagnostic Considerations for This Patient
This patient requires a systematic re-evaluation for other causes of chronic pharyngitis:
Bacterial Causes to Exclude
- Group C and G streptococci can cause severe or recurrent pharyngitis, though evidence is limited 4
- Group C streptococci have been associated with exudative tonsillitis and anterior cervical adenopathy in case-control studies 4
- Mycoplasma pneumoniae and Chlamydophila pneumoniae have been linked to recurrent respiratory symptoms in observational studies, though evidence is limited to specific outbreak settings 4
Non-Infectious Causes to Consider
- Chronic irritant exposure (smoking, environmental pollutants, occupational exposures)
- Gastroesophageal reflux disease (GERD) causing chronic posterior pharyngeal inflammation
- Allergic rhinitis with postnasal drip
- Chronic sinusitis
- Autoimmune conditions affecting the pharynx
Structural/Anatomical Issues
- Chronic tonsillar hypertrophy
- Peritonsillar pathology
- Anatomical variants causing chronic irritation
Recommended Diagnostic Workup
Obtain throat culture specifically requesting testing for:
- Group A, C, and G streptococci 4
- Consider serologic testing for Mycoplasma pneumoniae and Chlamydophila pneumoniae if recurrent symptoms suggest atypical bacterial infection 4
Additional investigations:
- Complete blood count with differential to assess for chronic infection or inflammatory process 5
- Consider referral to otolaryngology for direct laryngoscopy to evaluate for structural abnormalities or chronic inflammatory changes
- Trial of proton pump inhibitor therapy if GERD is suspected
- Allergy testing if allergic etiology is suspected
Management Approach
Do not prescribe antibiotics empirically without microbiological confirmation 6, 5
- The duration of symptoms (5 years) argues strongly against an acute bacterial infection requiring immediate antibiotic therapy
- Empiric antibiotic use without diagnosis leads to inappropriate treatment and promotes resistance 6
Symptomatic management while pursuing diagnosis:
- Analgesics such as ibuprofen or acetaminophen for symptom relief 6
- Avoid aspirin in this age group due to Reye syndrome risk 5
Common Pitfall to Avoid
Do not attribute every respiratory symptom to COVID-19 in the current pandemic era. 3 While co-occurrence of COVID-19 and bacterial pharyngitis has been reported, the temporal relationship in this case makes SARS-CoV-2 an impossible explanation for the chronic symptoms 3. The case report of GAS and COVID-19 co-occurrence emphasizes the importance of not having "singular focus on COVID-19" and missing other treatable causes of pharyngitis 3.