Most Likely Diagnosis and Management
This patient almost certainly has viral pharyngitis, and antibiotics should be withheld entirely—symptomatic treatment with ibuprofen or acetaminophen is the only appropriate management.
Diagnostic Reasoning
The clinical picture strongly points to a viral upper respiratory infection rather than bacterial pharyngitis:
- The presence of cough, nasal congestion, and systemic symptoms (fever, myalgias, chills) are classic viral features that argue strongly against Group A Streptococcus (GAS). 1, 2
- A negative rapid streptococcal test in an adult is sufficient to rule out GAS pharyngitis without requiring a backup throat culture, given the test's ≥95% specificity and the extremely low prevalence of GAS in adults (5–10%). 3, 1
- Recent household exposure to an upper respiratory infection further supports a viral etiology, as most acute pharyngitis cases are viral and occur in clusters. 3, 4
- The combination of cough with a negative strep test effectively excludes bacterial pharyngitis, as cough is a key distinguishing feature that points away from GAS toward viral infection. 1
Recommended Management
Symptomatic Treatment Only
- Offer ibuprofen (400–600 mg every 6–8 hours) or acetaminophen (650–1000 mg every 6 hours) for pain, fever, and body aches. 3, 1, 2
- Throat lozenges can provide additional comfort for the sore throat. 1
- Reassure the patient that symptoms typically resolve within 3–7 days without antibiotics, and that the illness is self-limited. 3, 1
What NOT to Do
- Do not prescribe antibiotics—they provide no clinical benefit for viral pharyngitis, expose the patient to unnecessary adverse effects (diarrhea, yeast infections, allergic reactions), and contribute to antimicrobial resistance. 3, 1
- Do not order a backup throat culture in this adult patient—it wastes resources and offers no clinical benefit after a negative rapid test. 1
- Do not test or treat the daughter or other household contacts prophylactically, even though she had strep last week; up to one-third of household members may be asymptomatic GAS carriers, and prophylactic treatment does not reduce subsequent infection rates. 1
Key Clinical Pitfalls to Avoid
- Do not be misled by the daughter's recent strep infection—this does not change the diagnostic approach or management when the patient's own test is negative and viral features are present. 1
- Do not prescribe antibiotics based on the severity of symptoms alone (fever, body aches)—these occur in both viral and bacterial infections, and laboratory confirmation is mandatory before treating. 3
- Recognize that earache in this context is likely referred pain from pharyngeal inflammation or Eustachian tube dysfunction secondary to nasal congestion, not a bacterial complication requiring antibiotics. 4, 5
When to Reassess
- If symptoms worsen significantly or persist beyond 7–10 days, consider alternative diagnoses such as bacterial sinusitis, infectious mononucleosis, or (rarely in adults) suppurative complications. 3, 5
- Fever persisting beyond 3–4 days or worsening after initial improvement warrants reevaluation for complications. 1, 6