What is the likely diagnosis and recommended management for a 5‑12‑year‑old child presenting with fever, conjunctivitis, sore throat, and headache?

Pharyngoconjunctival Fever: Adenoviral Infection

This school-age child most likely has pharyngoconjunctival fever (PCF) caused by adenovirus, and management should be entirely supportive with strict infection control measures—no antibiotics or testing for Group A Streptococcus is indicated. 1

Clinical Diagnosis

Classic Presentation of Pharyngoconjunctival Fever

• Fever, bilateral conjunctivitis, pharyngitis, and headache constitute the hallmark tetrad of PCF, which is caused predominantly by adenovirus types 3,4, and 7. 2, 3, 4
• The presence of conjunctivitis alongside pharyngitis strongly argues against bacterial pharyngitis and indicates a viral etiology; testing for Group A Streptococcus is not recommended when these viral features are present. 1
• Adenoviral conjunctivitis presents with bilateral bulbar and tarsal hyperemia, watery to mucoid discharge, follicular reaction on the palpebral conjunctiva, and often preauricular lymphadenopathy. 5
• Pharyngoconjunctival fever is most common in school-age children and frequently occurs in outbreaks associated with swimming pools or close-contact settings such as schools and camps. 3, 6

Key Differentiating Features

• The combination of red eyes (conjunctivitis) with sore throat immediately excludes the need for strep testing, as cough, rhinorrhea, hoarseness, and conjunctivitis are clinical features that strongly suggest viral origin. 1
• Fever and constitutional symptoms typically occur early in viral upper respiratory infections and may be accompanied by headache, myalgias, and malaise. 7
• Unlike bacterial pharyngitis, which presents with sudden-onset severe sore throat as the primary complaint, viral pharyngitis develops as part of a constellation of upper respiratory symptoms. 1, 7

Management

Supportive Care Only

• No antibiotics are indicated; management focuses entirely on symptomatic relief including analgesics (acetaminophen or ibuprofen, avoiding aspirin in children), adequate hydration, warm saline gargles, and rest. 1
• For conjunctivitis symptoms, warm soaks and artificial tear lubricants may relieve itching and burning; topical antibiotics are unnecessary and topical corticosteroids should be avoided as they can prolong viral shedding and lead to complications. 8, 5
• The illness is self-limiting, typically resolving within 5–7 days, though conjunctival symptoms may persist for 1–2 weeks. 7, 8, 6

Infection Control Measures

• Instruct the child to avoid touching their eyes, wash hands frequently, use disposable towels, and avoid school or group activities for as long as ocular discharge is present to minimize transmission. 8
• Adenovirus is extremely contagious through direct contact and fomites and is highly resistant to physical and chemical agents, making strict hygiene essential. 6
• Contagion is possible for up to 14 days after symptom onset, and the virus can survive on surfaces for extended periods. 6

When NOT to Test for Strep

• Do not perform rapid antigen detection testing (RADT) or throat culture when conjunctivitis, cough, rhinorrhea, or hoarseness are present, as these features indicate viral etiology. 1, 9
• Testing in the presence of obvious viral features leads to identification of asymptomatic Group A Streptococcus carriers rather than true infections, resulting in unnecessary antibiotic prescriptions. 1, 9
• In children under 3 years, GAS testing is generally not indicated because acute rheumatic fever is rare and streptococcal pharyngitis is uncommon in this age group; however, this school-age child (5–12 years) is in the typical age range for GAS, making the presence of conjunctivitis the key differentiating feature. 9

Red Flags Requiring Re-evaluation

• Return if symptoms persist beyond 10 days without improvement, worsen after initial improvement, or if severe symptoms develop such as high fever ≥39°C with purulent discharge, severe headache, facial swelling, visual changes, or respiratory distress. 7
• Development of corneal involvement (photophobia, decreased vision, epithelial keratitis) may occur with adenoviral infection and warrants ophthalmology referral. 5, 6
• Pseudomembranes on the conjunctiva or corneal subepithelial infiltrates can develop in severe cases and may require specialist management. 5, 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on the presence of pharyngitis alone when viral features such as conjunctivitis are present; this leads to unnecessary antibiotic use and antimicrobial resistance. 1
• Do not use topical corticosteroids for adenoviral conjunctivitis without ophthalmology consultation, as they can prolong viral shedding, increase the risk of bacterial superinfection, and cause elevated intraocular pressure. 5, 8
• Do not assume all red eyes with discharge require antibiotic drops; adenoviral conjunctivitis is self-limiting and topical antibiotics provide no benefit. 8
• Do not allow the child to return to school while symptomatic with conjunctival discharge, as this perpetuates outbreaks in close-contact settings. 8, 3