The Egyptian Journal of Hospital Medicine (January 2018) Vol.
70 (11), Page 2000-2003
Pediatric Pharyngitis: Etiology and Management Approaches
Taghreed Abdualaziz Almarshad1, Alanoud Saleh Alsaiari2, Waseem Morshed Qaq3,
Maria Mohammed Alshehab4, Waleed Abdulaziz Almosfer5, Mohammad Ridha Al Eid6,
Salha Ali Asery7, Marwa Khalifa Bindayna8
1 Ibn Sina National College, 2 King Saud Bin Abdulaziz University for Health Sciences,
3 Bayan Clinic, 4 Primary Health Care, 5 Majma'ah University, 6 King Fahad University Hospital,
7 King Khalid University, 8 King Hamad University Hospital (KHUH)
Corresponding Author: Taghreed Abdualaziz Almarshad - Toto-959@Hotmail.Com, Tel: +966 56 608 4136
ABSTRACT
Background: Acute pharyngitis is infection of the tonsils and the pharynx and is very common among children
and adolescents. They can be viral or bacterial in origin. The causative organism varies from geography, age, and
season of infection. Although viral pharyngitis is more common, the complications of bacterial pharyngitis can be
severe, and thus proper identification of the cause and management is very important.
Methodology: We conducted this review using a comprehensive search of MEDLINE, PubMed, and EMBASE,
January 1985, through February 2017. The following search terms were used: acute pharyngitis, pediatric
pharyngitis, bacterial infection, streptococcus pharyngitis, viral pharyngitis, rapid strept test, throat culture
Aim: In this review, we aim to study the common causative organisms of acute pharyngitis among pediatric
population and study the best course of management that must be followed.
Conclusion: Acute pharyngitis is a relatively common disease, with a viral cause most likely. An etiology due to a
streptococcal infection is a major concern and should always be ruled out due to its association with significant
morbidity and mortality. Long-term sequelae of streptococcal pharyngitis include rheumatic fever, rheumatic heart
disease, and acute post-streptococcal glomerulonephritis
Keywords: acute pharyngitis, pediatric pharyngitis, bacterial infection, streptococcus pharyngitis, viral
pharyngitis.
INTRODUCTION
Infection of the tonsils and the pharynx is called rule out the disease in cases of negative results,
acute pharyngitis. This is very common to occur especially in a highly suggestive clinical presentation
[2]
among children up to adolescence, and is due to .
various organisms. These organisms are highly
related to several factors including epidemiology, METHODOLOGY
geographical distribution, age, and season. Patients • Data Sources and Search terms
may present with sore throat that is associated with We conducted this review using a comprehensive
tonsillitis, nasopharyngitis, and/or search of MEDLINE, PubMed, and EMBASE,
tonsillopharyngitis. These findings along with January 1985, through February 2017. The following
rhinorrhea are strongly suggestive of a viral etiology. search terms were used: acute pharyngitis, pediatric
However, it is not proper to distinguish between pharyngitis, bacterial infection, streptococcus
different etiologies (bacterial, viral, or noninfectious) pharyngitis, viral pharyngitis, rapid strept test, throat
based solely on the physical examination. Untreated culture.
group A beta hemolytic streptococcus (GABHS) will The study was done after approval of ethical
strongly predispose to rheumatic fever, which makes board of King Saud Bin Abdulaziz university.
accurate diagnosis and management a major concern
especially in children older than two years [1]. In order • Data Extraction
to prevent this, it is recommended to administrate Two reviewers have independently reviewed the
antibiotics within the first nine days following studies, abstracted data, and disagreements were
symptoms. To confirm the diagnosis, GABHS rapid resolved by consensus. Studies were evaluated for
antigen detection assays provide a method that has a quality and a review protocol was followed
specificity of 99%. However, it has a relatively low throughout.
sensitivity (about 70%) which makes it difficult to
2000
Received: 20/12/2017 DOI: 10.12816/0044857
Accepted: 30/12/2017
Pediatric Pharyngitis…
ETIOLOGY Streptococci of Lancefield Groups C and G.
Viruses Acute pharyngitis that is associated with
Viral infections are responsible for most acute contaminated food has usually been reported to be
pharyngitis cases, and can be also accompanied with due to beta-hemolytic streptococci. An outbreak of
infections of other sites in the respiratory tract. Most acute pharyngitis among 85 patients was milk borne
common involved viruses include influenza A and B, and caused by S. zooepidemicus (Group C), and
rhinoviruses, parainfluenza viruses, and about third the patients developed later renal
coronaviruses. Some causative agents produce complications. Another similar outbreak with the
clinical signs and symptoms that help in the same organism and route of transmission was
establishment of an accurate diagnosis. Examples reported in a family of farmer. Food borne outbreaks
include infectious mononucleosis (caused by Epstein- of acute pharyngitis have also been reported
Barr virus), herpangina (caused by Coxsackie A), following Group G streptococci infections. Food in
pharyngoconjunctival fever, acute respiratory disease these cases included contaminated egg salad and
of military recruits (caused by adenovirus), chicken salad [7].
pharyngitis, gingivitis, and stomatitis (caused by The previous examples, along with other examples
herpes simplex virus), and cytomegalovirus present in the medical literature, represent important
mononucleosis (caused by cytomegalovirus). evidence that group C and G streptococci are strongly
However, even in these cases, it may sometimes be associated with pharyngitis epidemics. However,
challenging to clinically rule out streptococcal their strong involvement in endemic sore throat is still
pharyngitis [3]. controversial. Moreover, they are usually detected in
The presence of HSV-1 has been reported in most asymptomatic adults. In conclusion, current evidence
college students with acute pharyngitis. HSV-2 has suggest that they may be present in some cases of
also been reported to cause similar manifestations but pharyngitis [8].
it is more associated with sexual contact and In a previously published study, researchers found
transmission. HSV infections usually involve the that group C streptococci are significantly more likely
anterior oral cavity along with the posterior pharynx to be found in cultures obtained from adults who have
and cause gingivostomatitis that can be ulcerative or sore throats. Additionally, they found that clinical
vesicular. However, only one quarter of cases present manifestations associated with group C streptococci
with this typical classic presentation [4]. are similar to both culture-negative pharyngitis and
Another important causative organism that has Group A streptococcal pharyngitis. An observational
been responsible for acute pharyngitis is human study on students revealed that pharyngitis patients
immunodeficiency virus (HIV) during its acute phase. who have large positive cultures of S equisimilis have
In fact, it may present with sore throat along with clinical manifestations that are more similar to other
mononucleosis for days or weeks, myalgia, malaise, pyogenic infections that patients with negative
fever, photophobia, arthralgia, maculopapular rash, cultures. These findings were later confirmed by
and/or lymphadenopathy [5]. Cimolai et al [9], who were able to detect a positive
correlation between pharyngitis and group C and G
Bacteria streptococci, but could not detect correlation with
Streptococcus pyogenes (Group A streptococcus). Group A streptococci. It has also been reported and
The most common cause of bacterial pharyngitis is proven that several large outbreaks of pharyngitis
Group A streptococcus. This is specifically a major were attributed to group G streptococcus. Patients
concern due to its association with severe long-term with group G streptococcus were found to be
sequelae that include poststreptococcal significantly older that patients with group A
glomerulonephritis and acute rheumatic fever. streptococcus. Moreover group G streptococci were
Bacterial pharyngitis with Group A streptococcus has found to be strongly with later development of acute
a relatively high incidence among children between 5 glomerulonephritis [10].
and 15 years, and are responsible for up to 20% of M proteins are present in both group C and group
acute pharyngitis cases. However, it is considered G streptococci, and are generally similar to group A
significantly less common among infants and adults, regarding structure and functions. In addition,
and does not usually occur unless there is an outbreak virulent strains of group G streptococci are associated
or in endemic places (like military recruit camps) [6]. with expression of a C5a peptidase enzyme that is
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Taghreed Almarshad et al.
similar to group A. All this indicate the significant culture needs about two days to get results, causing
importance of non-group A streptococci in the significant possible morbidity in severe cases [15].
development of acute pharyngitis [11]. The fifth approach indicates the use of a rapid
Another rare cause of acute tonsillitis and pharyngitis antigen test followed with treatment of positive
is arcanobacterium haemolyticum. This cases are patients, and culture from negative patients. This
somewhat similar to pharyngitis due to a approach is commonly used as it allows for rapid
streptococcal infection, with the addition of a treatment with high sensitivity and specificity of the
scarlatiniform rash. A haemolyticum was found to diagnosis. However, it is associated with higher costs
occur more among young adults than children. for patients with pharyngitis due to causes other than
Treponema pallidum, Neisseria gonorrhea, Oral streptococci [16].
anaerobes, Yersinia enterocolitica, Francisella The final approach is to use a clinical system that
tularensis, Yersinia pestis and Corynbacterium provides a specific score and help achieving a proper
diphtheria were also found to be associated with a diagnosis. When using this score, patients with a low
significant number of acute pharyngitis [12; 13]. score results will not receive antibiotics treatment.
Whereas patients with a high score will receive
Management Approaches antibiotics treatment without further testing. Patents
Achieving ideal management in a pediatric patient with intermediate score results will require further
with acute pharyngitis is quite challenging, although investigations to either provide treatment or not. This
extremely important to prevent long-term approach is considered the best one as it has the
complications and sequelae, which include advantages of the previous approaches and avoids
peritonsillar abscess (PTA), acute rheumatic fever that disadvantages. It is recommended for patients of
(ARF) and rheumatic heart disease, and possibly all ages [14].
death in rare cases. Several approaches for proper
management have been suggested, with all having CONCLUSION
both advantages and disadvantages. The first In the emergency and ambulatory care settings,
approach include the empiric treatment of all patients acute pharyngitis is a relatively common disease, with
with pharyngitis with antibiotics. However, this a viral cause most likely. An etiology due to a
approach will lead to the unnecessary treatment of streptococcal infection is a major concern and should
about 90% of patients with pharyngitis that is not due always be ruled out due to its association with
to streptococcus. This unnecessary treatment is significant morbidity and mortality. Long-term
dangerous due to the high incidence of adverse events sequelae of streptococcal pharyngitis include
(like anaphylaxis) and the emergent of resistant rheumatic fever, rheumatic heart disease, and acute
bacteria [14]. post-streptococcal glomerulonephritis. Clinical
The second approach involves strict observation of presentation is usually not enough to establish and
all patients before administration of any test or confirm a diagnosis of streptococcal pharyngitis.
treatment. This approach will cause significant Therefore, it is crucial to use diagnostic tests like
decrease in costs, with minimal long term rapid antigen test and culture. Several approaches
complications, as most cases will resolve have been suggested to provide the ideal and most
spontaneously. However, rare complication like ARF proper management.
will occur and may sometimes result in death [15].
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