What is the appropriate management for an adult or child with no significant medical history presenting with a facial rash and sore throat?

Management of Facial Rash and Sore Throat

For an adult or child presenting with facial rash and sore throat, immediately perform a rapid antigen detection test (RADT) or throat culture to confirm or exclude Group A streptococcal pharyngitis, as clinical features alone cannot reliably distinguish bacterial from viral causes, and the presence of a rash suggests either streptococcal infection with scarlatiniform features or a viral etiology such as infectious mononucleosis. 1

Initial Diagnostic Approach

Determine if Testing is Indicated

• Perform microbiological testing (RADT or throat culture) if the patient presents with sudden onset sore throat, fever, tonsillopharyngeal erythema, tender anterior cervical lymphadenopathy, or absence of viral features (no cough, coryza, conjunctivitis, or hoarseness). 1

• Do not test if overt viral features are present: conjunctivitis, coryza (nasal discharge), cough, hoarseness, or discrete ulcerative stomatitis, as these strongly suggest viral pharyngitis. 1

• In children under 3 years, testing is generally not recommended unless risk factors exist (such as an older sibling with confirmed strep throat), as Group A streptococcal pharyngitis is uncommon in this age group. 1

Key Physical Examination Findings to Assess

For streptococcal pharyngitis:

• Tonsillopharyngeal erythema with or without patchy exudates 2
• Tender, enlarged anterior cervical lymph nodes 2
• Palatal petechiae ("doughnut lesions") 2
• Beefy red, swollen uvula 2
• Scarlatiniform rash (fine, sandpaper-like rash that may appear on face and body) 1

For viral pharyngitis (infectious mononucleosis):

• Posterior cervical lymphadenopathy (rather than anterior) 3
• Splenomegaly 3
• Diffuse maculopapular rash, especially if antibiotics (particularly amoxicillin) have been given 3

Management Based on Test Results

If RADT is Positive

Initiate antibiotic therapy immediately. 1

First-line treatment:

• Penicillin V: Children: 250 mg twice or three times daily for 10 days; Adolescents/Adults: 250 mg four times daily or 500 mg twice daily for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily for 10 days 1, 4

For penicillin allergy:

• First-generation cephalosporin, clindamycin, clarithromycin, or azithromycin 1, 5
• Azithromycin: 12 mg/kg once daily for 5 days in children; adults typically 500 mg day 1, then 250 mg days 2-5 5

Symptomatic treatment:

• Ibuprofen or acetaminophen for pain and fever relief 1
• Avoid aspirin in children due to Reye's syndrome risk 1
• Corticosteroids can be considered in adults with severe presentations (3-4 Centor criteria), but are not routinely recommended 1

If RADT is Negative

• In children and adolescents, perform a backup throat culture, as RADT sensitivity can be inadequate. 1

• In adults, backup culture is generally not necessary due to low incidence of Group A streptococcal infection and extremely low risk of rheumatic fever, though it can be considered. 1

• If negative strep test with splenomegaly and posterior cervical lymphadenopathy, consider infectious mononucleosis (EBV) and avoid empiric antibiotics. 3

• Provide symptomatic treatment only: analgesics/antipyretics for symptom relief. 1

Critical Pitfalls to Avoid

Do Not Treat Based on Clinical Features Alone

• Even experienced clinicians cannot reliably distinguish streptococcal from viral pharyngitis without laboratory confirmation. 1
• No combination of clinical findings is specific enough to definitively diagnose streptococcal pharyngitis. 2

Avoid Unnecessary Antibiotics

• Do not prescribe antibiotics for patients with 0-2 Centor criteria or negative testing, as this promotes resistance and provides no benefit. 1
• Antibiotics should not be used to prevent suppurative complications (quinsy, otitis media, sinusitis) or non-suppurative complications (rheumatic fever, glomerulonephritis) in low-risk patients. 1

Recognize Amoxicillin-Associated Rash in Mononucleosis

• If amoxicillin or ampicillin is given to a patient with unrecognized infectious mononucleosis, a diffuse maculopapular rash will develop in the majority of cases. 3
• This is not a true penicillin allergy but rather a reaction specific to the combination of these antibiotics with EBV infection. 3

Consider Dangerous Causes if Systemic Features Present

• If the patient has fever with rash plus headache, altered mental status, or appears systemically ill, consider life-threatening conditions such as meningococcemia, Rocky Mountain spotted fever, or toxic shock syndrome. 6, 7
• These require immediate empiric treatment without waiting for diagnostic confirmation. 6

Special Considerations

Asymptomatic Carriers

• Up to 20% of asymptomatic school children may carry Group A streptococci during winter/spring. 1
• A positive test may represent carriage with concurrent viral pharyngitis rather than true streptococcal infection. 1
• However, this distinction cannot be made clinically, so positive tests warrant treatment. 1

Follow-up Testing

• Posttreatment testing is not routinely recommended. 1
• Testing of household contacts is not routinely recommended unless a household member develops acute rheumatic fever. 1