Acute Viral Pharyngitis with Systemic Symptoms
This patient most likely has acute viral pharyngitis, and the appropriate next step is symptomatic treatment only—no antibiotics and no microbiological testing for Group A Streptococcus (GAS) are indicated at this time. 1, 2
Why This Is Viral (Not Bacterial)
The clinical presentation strongly argues against GAS pharyngitis and points to a viral etiology:
- Low back pain radiating down the legs with flu-like body malaise is characteristic of systemic viral infection, particularly influenza or other respiratory viruses 2
- Erythematous inflamed throat without tonsillar swelling or exudates lacks the classic findings of GAS (tonsillar exudates, palatal petechiae, beefy red uvula) 2, 3
- Viral pharyngitis accounts for the majority of acute pharyngitis cases in adults, with GAS responsible for only 5–10% of cases in this age group 2
- The myalgias and systemic symptoms are more consistent with influenza or other viral respiratory infections than with isolated bacterial pharyngitis 2
When NOT to Test for GAS
Do not perform rapid antigen detection testing (RADT) or throat culture in this patient because:
- Testing should be reserved for patients with fever plus sore throat plus absence of viral features 1, 2
- The presence of systemic myalgias and flu-like symptoms represents viral features that make GAS unlikely 2
- Testing patients with obvious viral presentations leads to false-positive results from asymptomatic GAS carriage (10–15% of the population) and unnecessary antibiotic use 2
Appropriate Management
Symptomatic treatment only:
- Ibuprofen or paracetamol for fever and pain relief 1
- Adequate hydration 2
- Warm saline gargles 2
- Topical anesthetics (lozenges) 2
- Rest 2
- Reassurance that viral pharyngitis is self-limiting and typically resolves within 3–7 days 2
Do not prescribe antibiotics for viral pharyngitis; they provide no benefit and contribute to antimicrobial resistance 1, 2
Red Flags Requiring Re-evaluation
Instruct the patient to return immediately if she develops:
- High fever (>38.3°C/101°F) that persists or worsens 2
- Severe or worsening sore throat with difficulty swallowing 2
- Tender anterior cervical lymphadenopathy 2
- Tonsillar exudates appearing on repeat examination 2
- Respiratory distress or signs of systemic toxicity 2
If these features develop, then perform RADT with backup throat culture if negative 1, 2
Common Pitfalls to Avoid
- Do not order GAS testing based solely on pharyngeal erythema when systemic viral symptoms are present; this leads to overdiagnosis and inappropriate antibiotic use 2
- Do not treat empirically with antibiotics based on clinical impression alone; even experienced physicians cannot reliably differentiate viral from bacterial pharyngitis without testing 2
- Do not assume all sore throats require antibiotics; the vast majority in young adults are viral and self-limiting 1, 2