What is the diagnosis and treatment for a patient with mild whitish exudate on the tonsil, fever, and throat pain, without swelling?

Diagnosis and Management of Tonsillar Exudate with Fever and Throat Pain

This presentation requires microbiological confirmation before initiating antibiotics, as viral infections frequently produce identical findings to bacterial pharyngitis, and clinical features alone cannot reliably differentiate between the two. 1, 2

Diagnostic Approach

Initial Clinical Assessment

The presence of tonsillar exudate with fever and throat pain requires systematic evaluation using clinical criteria:

• Apply the Centor criteria to determine likelihood of Group A Streptococcus (GAS): fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, and absence of cough 3
• Only proceed with testing if at least 2 Centor criteria are present - do not test patients with obvious viral features such as cough, rhinorrhea, hoarseness, or conjunctivitis 3, 1
• Never treat empirically without microbiological confirmation, as clinical impression alone overestimates bacterial infection even among experienced clinicians 3, 2

Features Suggesting Viral Etiology

• Presence of cough, rhinorrhea, hoarseness, or conjunctivitis strongly argues against bacterial infection 1
• Discrete ulcerative stomatitis or oral ulcers indicate viral infection 1, 2
• Viral pharyngitis accounts for 70-95% of tonsillitis cases 4, 5

Features Suggesting Bacterial (GAS) Etiology

• Sudden onset sore throat with pain on swallowing, fever, and absence of viral upper respiratory symptoms 1
• Tonsillopharyngeal erythema with or without exudates, tender enlarged anterior cervical lymph nodes, and palatal petechiae 1, 2
• Peak age 5-15 years, winter/early spring timing, and close contact with documented GAS case 1

Mandatory Microbiological Testing

Do not prescribe antibiotics based on clinical impression alone - the presence of exudate is not specific for bacterial infection 2

• Perform Rapid Antigen Detection Test (RADT) immediately if 2 or more Centor criteria are present 3, 6
• RADT has 90-96% specificity and 79-88% sensitivity for GAS 1
• If RADT is positive, proceed directly to antibiotic treatment 6
• If RADT is negative in children and adolescents, confirm with throat culture before withholding antibiotics 3, 1
• Throat culture remains the gold standard for diagnosis 1, 2

Treatment Based on Test Results

If GAS is Confirmed (Positive RADT or Culture)

First-line treatment is penicillin V 250-500 mg orally 2-3 times daily for 10 days due to proven efficacy, no resistance, narrow spectrum, and low cost 3, 1, 7

Alternative regimens:

• Amoxicillin is acceptable, especially in younger children, but use caution in adolescents due to risk of severe rash with concurrent Epstein-Barr virus 1, 6
• For non-anaphylactic penicillin allergy: narrow-spectrum cephalosporins (cefadroxil or cephalexin) for 10 days 1
• For true penicillin allergy or anaphylactic history: clindamycin (only ~1% resistance among GAS isolates) 1
• Macrolides/azalides (azithromycin, clarithromycin, erythromycin) are reasonable alternatives, but caution is advised due to 5-8% macrolide resistance rates 1, 8

Complete the full 10-day course (except azithromycin 5 days) to ensure bacterial eradication and prevent rheumatic fever 1

If Testing is Negative (Viral Etiology)

Do not prescribe antibiotics - management is supportive only 3, 1

Supportive care includes:

• Analgesics: acetaminophen or NSAIDs for pain and fever (avoid aspirin in children due to Reye syndrome risk) 1, 6
• Adequate hydration 1, 6
• Warm saline gargles and topical anesthetics 1
• Throat lozenges may provide additional relief 6
• Counsel that symptoms typically resolve within 1 week 6

Benefits of Antibiotic Treatment for Confirmed GAS

• Shortens sore throat duration by only 1-2 days (number needed to treat = 6 at 3 days) 6
• Primary benefit is prevention of acute rheumatic fever, peritonsillar abscess, and limiting spread to close contacts 1, 6
• Does not prevent acute glomerulonephritis 6

Critical Pitfalls to Avoid

• Do not assume exudates equal bacterial infection - viral infections frequently produce exudates clinically indistinguishable from bacterial causes 1, 2
• Do not rely on fever presence/absence to diagnose bacterial pharyngitis, as fever is neither sensitive nor specific 2
• Do not use broad-spectrum cephalosporins (cefdinir, cefixime, cefpodoxime) when narrow-spectrum options are available, as they promote antibiotic resistance 1
• Never use fluoroquinolones, tetracyclines, or sulfonamides for GAS pharyngitis 1
• Recognize that a patient may be a GAS carrier with concurrent viral pharyngitis 1