What is the diagnosis and recommended treatment for a 15-year-old male presenting with a 3-week history of cough, congestion, abdominal pain, sore throat, loose stools, and fever (hyperthermia)?

Diagnosis: Viral Upper Respiratory Tract Infection with Post-Infectious Cough

This 15-year-old male has a viral upper respiratory tract infection (URI) that has progressed to post-infectious cough, and the appropriate management is supportive care only—antibiotics are explicitly contraindicated. 1, 2

Clinical Reasoning

The 3-week duration with fever, cough, congestion, sore throat, abdominal pain, and loose stools strongly suggests a viral URI that has evolved into post-infectious cough. 2 The combination of respiratory and gastrointestinal symptoms is typical for viral infections in adolescents, where 75-90% of pharyngitis cases are viral. 3

Key diagnostic features that confirm this is NOT bacterial:

• Non-purulent presentation (no mention of exudates)
• Gastrointestinal symptoms (nausea, loose stools, abdominal pain) point to viral etiology 2
• Three-week timeline fits post-infectious cough (defined as cough persisting 3-8 weeks after acute respiratory infection) 1
• Fever at presentation is consistent with the initial viral phase 2

Critical Rule-Outs Before Proceeding

You must exclude Group A Streptococcal pharyngitis before dismissing antibiotics entirely. 4, 3 Perform a rapid antigen detection test (RADT) or throat culture—do not prescribe antibiotics without positive testing. 3 The American College of Physicians states that only 10-25% of adolescents with pharyngitis have GAS infection, and empiric treatment contributes to resistance. 3

Red flags requiring immediate hospital referral (none present here, but assess): 2

• Respiratory distress or oxygen saturation <92%
• Cyanosis
• Severe dehydration
• Altered consciousness or drowsiness
• Signs of septicemia

Recommended Treatment Algorithm

Step 1: Supportive Care (Primary Management)

Initiate symptomatic relief measures immediately: 2, 3

• Antipyretics for comfort: Ibuprofen or acetaminophen (NSAIDs are more effective than acetaminophen for pharyngitis pain) 3

  • Never aspirin in patients under 16 years due to Reye's syndrome risk 3
  • Use antipyretics for patient comfort, not to normalize temperature—fever aids immune response 3

• Hydration and rest: Adequate fluid intake and rest 2

• Nasal symptoms: Saline nasal irrigation, intranasal corticosteroids if congestion is significant 2

• Throat symptoms: Throat lozenges as needed 2

• For cough: The American Thoracic Society recommends guaifenesin 200-400 mg every 4 hours (up to 6 times daily) as initial management for post-viral cough 1

Step 2: If Cough Persists Beyond 1-2 Weeks

Add inhaled ipratropium bromide 2-3 puffs (17-34 mcg per puff) four times daily if quality of life is significantly affected. 1 This has the strongest evidence for attenuating post-infectious cough, with expected response within 1-2 weeks. 1

Step 3: If Symptoms Persist Beyond 3-5 Days or Worsen

Mandatory reassessment is required if: 2

• Fever persists for 4-5 days
• Symptoms persist beyond 10 days
• Worsening after initial improvement
• Development of severe symptoms
• Severe earache
• Vomiting >24 hours

Reassessment at 48-72 hours is critical to detect complications such as pneumonia or bacterial superinfection that would require antibiotic therapy. 2

What NOT to Do

Antibiotics are explicitly contraindicated for post-infectious cough and viral URI. 1, 2 The American College of Chest Physicians states that antibiotics should NOT be prescribed for common cold, nonspecific upper respiratory infection, acute bronchitis, or viral pharyngitis, as they cause more harm than benefit and contribute to antibiotic resistance. 2 Therapy with antibiotics has no role in post-infectious cough unless there is clear evidence of bacterial sinusitis or early pertussis infection. 1

Do not prescribe prednisone at this stage. 1 Oral prednisone (30-40 mg daily for 5-10 days) is reserved only for severe paroxysms that significantly impair quality of life, and only after ruling out other causes. 1

Common Pitfalls to Avoid

• Failing to test for GAS before dismissing antibiotics: Always confirm with RADT or culture 3
• Prescribing antibiotics empirically: Over 60% of adults with sore throat receive unnecessary antibiotics, contributing to resistance 3
• Misinterpreting colored sputum as bacterial: Green or colored sputum does NOT indicate bacterial infection—most short-term coughs are viral even when producing colored phlegm 1
• Not scheduling follow-up: Instruct the patient to return if fever develops, hemoptysis occurs, or symptoms worsen 1

Timeline Expectations

• Acute post-viral symptoms generally respond to supportive treatment within 10-14 days 1
• Post-infectious cough typically resolves within 3-8 weeks 1
• If cough extends beyond 8 weeks, reclassify as chronic cough and systematically evaluate for upper airway cough syndrome (UACS), asthma, and GERD 1