What are the typical symptoms and signs of bacterial pharyngitis?

Symptoms of Bacterial Pharyngitis

Bacterial pharyngitis, particularly Group A Streptococcus, typically presents with sudden-onset severe sore throat, high fever (≥101°F/38.3°C), tonsillar exudates, tender anterior cervical lymphadenopathy, and notably lacks viral upper respiratory symptoms such as cough, rhinorrhea, hoarseness, or conjunctivitis. 1, 2

Classic Presenting Symptoms

Throat-Specific Symptoms:

• Sudden onset of severe sore throat that worsens with swallowing is the hallmark symptom 1, 2, 3
• Pain on swallowing (odynophagia) is commonly reported 2
• Throat discomfort typically begins abruptly rather than gradually 2, 3

Systemic Symptoms:

• High fever (typically ≥101°F or 38.3°C, often reaching 101-104°F) 1, 2, 3
• Headache is frequently present 1, 2, 3
• Chills and malaise accompany the acute illness 3
• Nausea, vomiting, and abdominal pain may occur, especially in children 1, 2, 4

Physical Examination Findings

Oropharyngeal Signs:

• Tonsillopharyngeal erythema (redness) with or without patchy discrete exudates 1, 2, 5
• Tonsillar swelling and enlargement 2, 4
• Palatal petechiae ("doughnut lesions") are highly suggestive when present 1, 2
• Beefy red, swollen uvula 2

Lymph Node Findings:

• Tender, enlarged anterior cervical lymph nodes (lymphadenitis) are characteristic 1, 2, 4, 3

Associated Rash:

• Scarlatiniform rash may be present in scarlet fever 1

Critical Distinguishing Features: What Bacterial Pharyngitis Does NOT Have

The absence of viral upper respiratory symptoms is key to suspecting bacterial etiology 1, 5:

• No cough (presence strongly suggests viral cause) 1, 2, 5
• No rhinorrhea or nasal congestion (coryza) 1, 2, 5
• No hoarseness 1, 2, 5
• No conjunctivitis 1, 2, 5
• No oral ulcers or discrete ulcerative stomatitis 2, 5
• No diarrhea (more typical of viral illness) 1, 5

Age and Seasonal Patterns

• Peak incidence occurs in children aged 5-15 years (25-40% of pharyngitis cases in this age group are bacterial) 1, 2, 4
• Only 5-15% of adult pharyngitis is bacterial 1, 5
• Winter and early spring predominance in temperate climates (November-May) 1, 2, 5
• Uncommon in children younger than 3 years unless household exposure exists 1, 2, 4

Important Clinical Caveats

Clinical diagnosis alone is unreliable:

• Even experienced clinicians cannot definitively distinguish bacterial from viral pharyngitis based solely on symptoms and signs 1, 2, 5
• Only 35-50% of clinically suspected cases are culture-positive for Group A Streptococcus 2, 4
• Microbiological confirmation with rapid antigen detection test or throat culture is mandatory before prescribing antibiotics 1, 2, 5

Asymptomatic carriage:

• 10-20% of school-age children are asymptomatic GAS carriers during peak season 2, 5
• A positive test in a patient with predominantly viral symptoms may reflect carriage rather than active infection 2, 5

When to Suspect Bacterial Pharyngitis

Test for Group A Streptococcus when the patient has:

• Sudden-onset sore throat with fever 2, 5
• Tonsillar findings (erythema, exudates, swelling) 2, 4
• Tender anterior cervical lymphadenopathy 2, 4
• AND absence of viral features (no cough, rhinorrhea, hoarseness, conjunctivitis) 1, 2, 5

Do NOT test when:

• Obvious viral symptoms dominate (cough, rhinorrhea, conjunctivitis present) 1, 2, 5
• Patient is well-appearing without fever or systemic symptoms 2