What Else Causes Acute Pharyngitis That Isn't Group A Streptococcus?

Patient Presentation
A 6-year-old female came to clinic with a 1 day history of sore throat and fever to 102° Fahrenheit.
She also had a runny nose but no cough, ear pain, abdominal pain, nausea, emesis or rash. Her brother had similar symptoms as did several students in her class.
There were known streptococcal infections in her school.
The past medical history showed 1 previous strep throat and 2 ear infections.
The review of systems was otherwise normal.
The pertinent physical exam showed a mildly ill-appearing female with a temperature to 38.4° Celsius. Her vital signs and growth parameters were otherwise normal.
HEENT examination revealed clear rhinorrhea and bilateral tympanic membranes with small effusions, normal landmarks and mobility.
She had an erythematous pharynx and tonsils without palatal petechiae or exudates.
She also had anterior cervical nodes bilaterally that were < 0.5 cm.
Lungs were clear and her skin examination reveled no rashes.
The laboratory evaluation included a rapid strep test that was negative.
The diagnosis of acute pharyngitis most likely caused by a respiratory virus was made.
The parents were given instructions for symptomatic care and when to telephone concerning new or progressing symptoms.
Her throat culture eventually was negative.

Acute pharyngitis is a common problem accounting for 1-2% of all outpatient visits.
Patients usually complain of pain to various degrees, fever and erythema of the pharynx.
Acute pharyngitis is more common in the colder months of the year.

The most important bacterial cause is Streptococcus pyogenes, or beta-hemolytic, group A streptococcus (GAS). It causes 15-30% of tonsillopharyngitis in school age children.
GAS is often spread between family members with children being the reservoir.
Common signs of GAS include erythema and exudates of the tonsils and pharynx, petechiae on the soft palate, anteriorcervical adenitis and scarlatiniform rash.
Common symptoms of GAS include pharyngeal pain, fever, headache, abdominal pain, nausea and vomiting.
Treatment for GAS usually includes penicillins, cephalosporins and macrolide antibiotics.

Learning Point
Acute pharyngitis is most commonly caused by viruses, particularly rhinovirus, coronavirus and influenza.
Commons signs of non-GAS infection include conjunctivitis, stomatitis, and ulcerations of the pharynx.
Common symptoms of non-GAS infection include cough, coryza, hoarseness and diarrhea.

Other causes of acute pharyngitis that are not GAS include:

  • Bacterial
    • Anaerobes, mixed
    • Arcanobacterium haemolyticum
    • Chlamydia
    • Corynebacterium diphtheriae
    • Francisella tularensis
    • Neisseria gonorrhoeae
    • Streptococcus – Groups C and G
    • Treponema pallidum
    • Yersinia enterocolitica
    • Yersinia pestis
  • Viral
    • Adenovirus
    • Coronavirus
    • Coxsackievirus – A
    • Cytomegalovirus
    • Epstein-Barr virus
    • Herpes simplex virus – Types 1 and 2
    • Human Immunodeficiency Virus
    • Influenza – Types A and B
    • Parainfluenza virus
    • Rhinovirus
  • Other
    • Chlamydophilia psittaci
    • Chlamydophilia pneumoniae
    • Mycoplasma pneumoniae

Questions for Further Discussion
1. Within how many days of symptom onset should GAS be treated?
2. What is the sensitivity and specificity of rapid strep tests?
3. What are the potential complications of acute pharyngitis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sore Throat and Throat Disorders and at Pediatric Common Questions, Quick Answers for this topic: Strep Throat

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Gerber MA.
Diagnosis and treatment of pharyngitis in children.
Pediatr Clin North Am. 2005 Jun;52(3):729-47..

Alcaide ML, Bisno AL.
Pharyngitis and epiglottitis.
Infect Dis Clin North Am. 2007;21(2):449-69.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Professionalism
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    September 22, 2008