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Streptococcal pharyngitis in Adult
See also in: Oral Mucosal Lesion
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Streptococcal pharyngitis in Adult

See also in: Oral Mucosal Lesion
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Contributors: Anand N. Bosmia MD, James H. Willig MD, MSPH
Other Resources UpToDate PubMed

Synopsis

Streptococcal pharyngitis, or strep throat, is an acute infection and inflammation of the pharynx that affects both children and adults. The most common bacterial etiology of pharyngitis is group A beta-hemolytic Streptococcus (GABHS, or Streptococcus pyogenes). The infection is transmitted via respiratory secretions.

Demographics:
  • Responsible for 5% to 20% of cases of pharyngitis in adults.
  • Responsible for 15% to 30% of cases of pharyngitis in children.
  • Most commonly occurs in children between 5 and 15 years of age.
Symptoms (Often Abrupt Onset):
Typical
  • Pain or difficulty swallowing
  • Fever
  • Chills
  • Malaise
  • Headache – Frequently frontal in location
Variants
  • Younger children – Abdominal pain, nausea, and vomiting
  • Severe unilateral throat pain should raise concern for a peritonsillar or retropharyngeal abscess, especially if this symptom arises or progresses several days after onset of symptoms. Inability to swallow, or odynophagia, should raise concern for a peritonsillar or retropharyngeal abscess.
Signs:
Typical
  • Pharyngeal erythema
  • Exudate (gray-white), tonsillar pillars or posterior pharynx; occasional palatine petechiae, erythema and edema of the uvula
  • Anterior cervical lymphadenopathy (classic angle of jaw)
Variants
  • Scarlet fever – Usually face sparing, punctate, erythematous, blanchable, sandpaper-like exanthem that may be accentuated in skin folds and creases (Pastia's lines) and may desquamate during convalescence; bright red tongue with inflamed papillae (strawberry tongue); erythematous pharynx and tonsils covered with exudate.
  • Children less than 3 years of age – Coryza, purulent nasal discharge, excoriated nares (streptococcosis), and generalized adenopathy.
Risk Factors:
  • Exposure to a person with known streptococcal pharyngitis.
  • History of acute rheumatic fever or rheumatic heart disease.
Timeline:
  • The incubation period is 24-72 hours.
  • In most people, fever resolves within 3-5 days, and throat pain resolves within 1 week, even without specific treatment.
  • Patients with untreated GABHS pharyngitis are infectious during the acute phase and for 1 week after.
  • Late winter and early spring are peak GABHS seasons.
Complications of GABHS Illness:
Suppurative
  • Bacteremia
  • Cervical lymphadenitis
  • Endocarditis
  • Fasciitis/myositis
  • Mastoiditis
  • Meningitis
  • Otitis media
  • Perianal dermatitis in children
  • Peritonsillar/retropharyngeal abscess (quinsy) – Patient has toxic appearance, "hot potato voice," fluctuant peritonsillar mass, and asymmetric deviation of the uvula.
  • Pneumonia
  • Sinusitis
  • Toxic shock
Nonsuppurative
  • Post-streptococcal glomerulonephritis – Hematuria and edema with history of a recent streptococcal infection (elevated anti-streptolysin O titer).
  • Acute rheumatic fever – Major (carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) and minor (arthralgias, fever, elevated acute-phase reactants, prolonged PR interval).
  • Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection.
  • Post-streptococcal autoimmune dystonia secondary to striatal necrosis.
  • Post-streptococcal reactive arthritis.
  • Sydenham's chorea and other autoimmune movement disorders.

Codes

ICD10CM:
J02.0 – Streptococcal pharyngitis

SNOMEDCT:
43878008 – Streptococcal sore throat

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Differential Diagnosis & Pitfalls

Common pitfalls may include missing the diagnosis because of the variability of symptoms and signs and the range of the illness's severity.

When assessing a patient for sore throat, the differential diagnosis should include the following:

Other bacterial pharyngitides – Less common causes are Arcanobacterium haemolyticum, Mycoplasma pneumoniae, Chlamydia pneumoniae, Neisseria gonorrhoeae, and groups C and G streptococci.

Gonococcal pharyngitis (see gonorrhea, primary infection) – Occurs in sexually active individuals; presents with fever, severe sore throat, dysuria, and a characteristic greenish exudate.

Diphtheria – Characterized by moderately sore throat, low-grade fever, and an adherent grayish membrane with surrounding inflammation of the tonsils, pharynx, and nasal passages; presumptive diagnosis if serosanguineous nasal discharge and a grayish-white pharyngeal membrane that is exudative and extends to the uvula and soft palate in association with pharyngitis, tonsillitis, and cervical lymphadenopathy.

Viral pharyngitis – Most common cause of sore throat; suggested by coryza, conjunctivitis, malaise or fatigue, hoarseness, and low-grade fever; atypical symptoms and signs are mouth breathing, vomiting, abdominal pain, and diarrhea.

Infectious mononucleosis – Epstein-Barr virus; cytomegalovirus, most common in patients 15-30 years of age; less likely if posterior cervical lymphadenopathy is absent; associated with hepatosplenomegaly; if amoxicillin or ampicillin is given, 90% of these patients will develop a classic maculopapular rash.

Kawasaki disease – Most often affects children younger than 5 years; characterized by sore throat, fever, bilateral non-purulent conjunctivitis, anterior cervical node enlargement, erythematous oral mucosa, and an inflamed pharynx with a strawberry tongue; and rash.

Gastroesophageal reflux disease
– Causes pain by direct irritation of the pharyngeal tissue by stomach acid.

Postnasal drip secondary to allergic rhinitis or sinusitis – Causes chemical irritation and repeated drying that yield sore throat.

Persistent cough.

Thyroiditis – Anterior neck pain that may be mistaken for pharyngitis; typically associated with more local tenderness to palpation compared with pharyngitis.

Foreign body/trauma.

Referred dental pain.

Smoking.

Immunocompromised Patient Considerations: 
Candidiasis – Consider in patients who have AIDS or who are using nasal or inhaled corticosteroids.

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Last Updated: 05/09/2013
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Streptococcal pharyngitis in Adult
See also in: Oral Mucosal Lesion
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Streptococcal pharyngitis : Abdominal pain, Cervical lymphadenopathy, Chills, Fever, Headache, Nausea/vomiting, Oral petechiae, Tonsillar exudates, Dysphagia, Oropharyngeal erythema, Pharyngitis
Clinical image of Streptococcal pharyngitis
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