What is the appropriate diagnosis and treatment for a female patient with sudden onset of severe throat pain, described as feeling like swallowing glass, without fever or nasal symptoms, and a history of recent intimate contact, despite no known sick contacts and no previous history of strep throat?

Diagnosis and Management of Severe Acute Pharyngitis with Recent Intimate Contact

This patient requires immediate testing for Group A Streptococcus (GAS) pharyngitis with rapid antigen detection test (RADT) and/or throat culture, but given the history of recent intimate contact, you must also test for Neisseria gonorrhoeae pharyngitis, which can present identically to streptococcal pharyngitis in sexually active individuals. 1

Differential Diagnosis Priority

The sudden onset of severe throat pain ("swallowing glass"), absence of viral features (no cough, coryza, or conjunctivitis), and accompanying headache strongly suggest bacterial pharyngitis rather than viral etiology. 1 However, the history of recent intimate contact with an asymptomatic partner is a critical red flag that distinguishes this case from routine streptococcal pharyngitis. 1

Key Clinical Features Supporting Bacterial Etiology:

• Sudden onset of severe sore throat 1, 2
• Absence of viral features: no cough, coryza, conjunctivitis, or diarrhea 1
• Severe pain disrupting sleep suggests bacterial rather than viral cause 1
• Headache is consistent with GAS pharyngitis 1
• No fever does not exclude bacterial pharyngitis, though it makes it less typical 1

Critical Consideration - Gonococcal Pharyngitis:

N. gonorrhoeae can cause acute pharyngitis in sexually active individuals that is clinically indistinguishable from streptococcal pharyngitis. 1 The partner being asymptomatic is entirely consistent with gonococcal infection, as pharyngeal gonorrhea is frequently asymptomatic in carriers. 1

Diagnostic Testing Algorithm

Step 1: Perform RADT for GAS immediately 3, 4

• If positive, proceed to treatment for GAS
• If negative, obtain backup throat culture (mandatory in this age group if she is under 40) 5, 4

Step 2: Obtain pharyngeal culture for N. gonorrhoeae 1

• This is non-negotiable given the sexual history
• Specimen should be obtained from the posterior pharynx and tonsillar surfaces 5
• Standard throat swabs for GAS will not detect gonorrhea; specific culture media is required 1

Do NOT start antibiotics before obtaining cultures for both organisms. 3 Treatment without microbiologic confirmation leads to inappropriate antibiotic use in the majority of cases. 3

Treatment Based on Test Results

If GAS Positive:

First-line treatment: Penicillin V 500 mg orally 2-3 times daily for 10 days 1, 3

• Alternative: Amoxicillin 500 mg twice daily for 10 days 1
• For penicillin allergy: First-generation cephalosporin, clindamycin, or azithromycin 1, 4

Critical: Complete the full 10-day course. 5 Shorter durations lack evidence for preventing rheumatic fever. 5

If Gonococcal Pharyngitis Confirmed:

Treatment requires different antibiotics than standard GAS therapy, typically ceftriaxone-based regimens per CDC sexually transmitted infection guidelines. 1 Consult current STI treatment guidelines as resistance patterns evolve.

If Both Tests Negative:

Consider viral pharyngitis (self-limited, symptomatic treatment only) or other causes including Epstein-Barr virus, though the absence of fever and sudden onset make this less likely. 1, 6

Symptomatic Management (Regardless of Etiology)

• NSAIDs or acetaminophen for pain and fever control 3
• Warm salt water gargles if patient can tolerate 3
• Antibiotics can be started up to 9 days after symptom onset and still prevent rheumatic fever 5
• Patient becomes non-contagious after 24 hours of appropriate antibiotic therapy (if bacterial) 5

Critical Pitfalls to Avoid

1. Never treat based on clinical impression alone without microbiologic confirmation 3 - even with classic symptoms, only 15-30% of adults with pharyngitis have GAS 7

2. Do not miss gonococcal pharyngitis 1 - this requires specific testing and different treatment; standard GAS antibiotics may not adequately treat gonorrhea

3. Do not use broad-spectrum antibiotics empirically 3 - if GAS is confirmed, narrow-spectrum penicillin is superior

4. Do not perform follow-up cultures on asymptomatic patients who completed appropriate therapy 3

When to Reassess

If symptoms persist beyond 3-5 days of antibiotic therapy, reassess the diagnosis and consider:

• Alternative pathogens (including gonorrhea if not initially tested) 5
• Peritonsillar or parapharyngeal abscess 3
• Infectious mononucleosis 3
• Treatment failure requiring alternative antibiotics 3

The sexual history in this case elevates gonococcal pharyngitis from a rare consideration to a must-rule-out diagnosis that requires specific testing beyond routine strep testing. 1