In a healthy 21‑year‑old male with fever, cervical lymphadenopathy, tonsillar exudates and a three‑day history of dyspnea, what is the appropriate management?

Management of Severe Pharyngitis with Dyspnea in a Young Adult

This patient requires immediate evaluation for airway compromise and urgent testing for Group A Streptococcus, with consideration of life-threatening complications such as peritonsillar abscess or epiglottitis given the three-day history of dyspnea.

Immediate Assessment for Airway Compromise

The presence of dyspnea (trouble breathing) for three days in the context of pharyngitis is a red flag that demands urgent evaluation for airway-threatening complications. 1

• Assess for signs of airway obstruction: difficulty swallowing, drooling, muffled "hot potato" voice, inability to handle secretions, stridor, or respiratory distress. 1
• Examine for peritonsillar abscess: unilateral tonsillar swelling, uvular deviation, trismus (difficulty opening mouth), and asymmetric soft palate bulging. 1
• Consider epiglottitis or parapharyngeal abscess: severe dysphagia, neck tenderness or swelling, and toxic appearance warrant immediate ENT consultation and possible imaging. 1
• If airway compromise is suspected, do not delay—secure the airway and obtain urgent ENT or anesthesia consultation. 1

Risk Stratification for Group A Streptococcus

Once airway safety is confirmed, apply the modified Centor criteria to determine the likelihood of bacterial infection: 2

• Fever ≥38°C (101°F): +1 point 2
• Absence of cough: +1 point 2
• Tender anterior cervical lymphadenopathy: +1 point 2
• Tonsillar swelling or exudate: +1 point 2
• Age 21 years: 0 points (ages 15-44 receive 0 points; age <15 receives +1, age ≥45 receives -1) 2

This patient likely scores 3-4 points (fever, exudates, lymphadenopathy, no cough mentioned), indicating a 32-56% probability of Group A Streptococcus infection. 3

Diagnostic Testing

• Perform a rapid antigen detection test (RADT) immediately. 2, 3
• A positive RADT is diagnostic for GAS pharyngitis and warrants immediate antibiotic therapy. 4, 3
• In adults, a negative RADT does not require backup throat culture because of the low risk of rheumatic fever in this age group and the high specificity (≥95%) of RADT. 4, 3
• Do not delay testing or treatment while awaiting culture results if clinical suspicion is high (score ≥3). 2

Antibiotic Treatment for Confirmed GAS

If RADT is positive, initiate antibiotics immediately: 2, 3

• First-line: Penicillin V 250-500 mg orally 2-3 times daily for 10 days, or amoxicillin 500 mg twice daily for 10 days. 2, 3, 5

  • Penicillin remains the gold standard due to proven efficacy, narrow spectrum, zero resistance, safety, and low cost. 2, 4
  • A full 10-day course is essential to eradicate bacteria and prevent acute rheumatic fever. 2, 6

• Penicillin allergy (non-anaphylactic): Narrow-spectrum cephalosporin (cefadroxil or cephalexin) for 10 days. 4

• True penicillin allergy or anaphylaxis: Clindamycin (≈1% GAS resistance) or a macrolide such as azithromycin (5-8% resistance; use with caution). 4

Antibiotics shorten symptom duration by only 1-2 days (number needed to treat = 6 at 3 days, 21 at 1 week), but they prevent serious complications including acute rheumatic fever, peritonsillar abscess, and further transmission. 2

Symptomatic Management

Regardless of etiology, provide aggressive symptomatic relief: 2, 3

• Analgesics: Ibuprofen or acetaminophen for pain and fever. 3
• Throat lozenges for topical relief. 3
• Adequate hydration, warm saline gargles, and rest. 2

If Testing is Negative or Viral Features Predominate

• Do not prescribe antibiotics. 2, 4
• Reassure the patient that typical sore throat duration is less than 7 days. 2, 3
• Continue symptomatic care only. 2

Special Considerations for Dyspnea

The three-day history of dyspnea is atypical for uncomplicated pharyngitis and raises concern for:

• Peritonsillar abscess: Requires incision and drainage plus antibiotics. 1
• Lemierre syndrome (Fusobacterium necrophorum): Rare but life-threatening in adolescents/young adults; presents with severe pharyngitis, neck pain/swelling, and septic thrombophlebitis of the internal jugular vein. 1
• Infectious mononucleosis (EBV): Can cause marked tonsillar hypertrophy and airway narrowing; avoid amoxicillin due to risk of severe rash. 4

If dyspnea persists or worsens despite treatment, obtain lateral neck X-ray or CT imaging to exclude abscess, and consider blood cultures if systemic toxicity is present. 1

Common Pitfalls to Avoid

• Do not assume all exudative pharyngitis is bacterial—viruses (adenovirus, EBV) frequently cause exudates. 4
• Do not treat based on clinical impression alone without microbiological confirmation—this leads to unnecessary antibiotic use in 50-70% of cases. 2, 4
• Do not dismiss dyspnea as a minor symptom—it may signal impending airway compromise or deep space infection. 1
• Do not prescribe antibiotics for fewer than 10 days (except azithromycin 5 days)—shorter courses increase treatment failure and recurrence. 6
• Do not test or treat asymptomatic household contacts. 4

Follow-Up

• Instruct the patient to return immediately if dyspnea worsens, drooling develops, or inability to swallow occurs. 1
• Symptoms should improve within 48-72 hours of starting antibiotics; if not, re-evaluate for complications or alternative diagnoses. 2
• Routine post-treatment testing is unnecessary unless symptoms persist or recur. 4