CLINICAL MIMICS: AN EMERGENCY MEDICINE-FOCUSED REVIEW OF

STREPTOCOCCAL PHARYNGITIS MIMICS

Michael Gottlieb, MD, RDMS,* Brit Long, MD,† and Alex Koyfman, MD‡
*Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, †Department of Emergency Medicine, San
Antonio Military Medical Center, Fort Sam Houston, Texas, and ‡Department of Emergency Medicine, The University of Texas
Southwestern Medical Center, Dallas, Texas
Reprint Address: Brit Long, MD, Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive,
Fort Sam Houston, TX 78234

, Abstract—Background: Pharyngitis is a common disease and management of ED patients. Published by Elsevier Inc.
in the emergency department (ED). Despite a rela-tively low
incidence of complications, there are many dangerous
conditions that can mimic this disease and are essential for the , Keywords—pharyngitis; sore throat; odynophagia;
emergency physician to consider. Objective: This article streptococcus; mimic
provides a review of the evaluation and manage-ment of group
A b-hemolytic Streptococcal (GABHS) phar-yngitis, as well CASE REPORT
as important medical conditions that can mimic this disease.
Discussion: GABHS pharyngitis often presents with fever, A 22-year-old male presented to the emergency department
sore throat, tonsillar exudates, and ante-rior cervical (ED) with sore throat for the past week. He complained of
lymphadenopathy. History and physical exam-ination are fever, throat pain, difficulty swallowing, and pain with neck
insufficient for the diagnosis. The Centor criteria or McIsaac movement. He had a fever of 38 C, heart rate of 115 beats/
score can help risk stratify patients for subse-quent testing or
min, and blood pressure of 108/62 mm Hg. On examination,
treatment. Antibiotics may reduce symptom duration and
he was in mild distress but was able to tolerate his oral se-
suppurative complications, but the effect is small. Rheumatic
fever is uncommon in developed coun-tries, and shared cretions. His oropharyngeal examination was significant for
decision making is recommended if antibi-otics are used for tonsillar exudates without uvular deviation. He had no
this indication. Oral analgesics and topical anesthetics are sublingual edema, but decreased neck range of motion was
important for symptom management. Physicians should present. An x-ray study demonstrated retropharyngeal soft-
consider alternate diagnoses that may mimic GABHS tissue edema, which was confirmed to be an abscess on
pharyngitis, which can include epiglot-titis, infectious computed tomography (CT). He was given intravenous
mononucleosis, Kawasaki disease, acute retroviral syndrome, ampicillin-sulbactam and methylprednisolone. Otolaryn-
Lemierre’s syndrome, Ludwig’s angina, peritonsillar abscess, gology was consulted, and he was taken to the operating room
retropharyngeal abscess, and viral pharyngitis. A focused
for surgical drainage.
history and physical exam-ination can help differentiate these
conditions. Conclusions: GABHS may present similarly to
other benign and potentially deadly diseases. Diagnosis and INTRODUCTION
treatment of pharyngitis should be based on clinical
evaluation. Consid-eration of pharyngitis mimics is important Pharyngitis is a common condition evaluated and
in the evaluation managed in the ED, with more than 2 million ED visits

1
2 M. Gottlieb et al.

annually (1–3). Patients typically present with sore Evaluation of patients with concern for GABHS
throat, fever, and inflammation of the pharynx (2–4). phar-yngitis includes consideration of other potentially
Group A b-hemolytic Streptococcus (GABHS) accounts dangerous conditions, followed by the use of risk
for up to 30% of sore throats in pediatric patients and 5– stratifi-cation supplemented by further testing as
15% in adult patients (3–6). In the United States, needed. The Centor Criteria, developed in 1981,
GABHS pharyngitis has been estimated to cost more consists of four find-ings that are suggestive of GABHS
than $500 million in health care costs each year (7). infection (14,20,21). This tool allows for initial risk
While most cases resolve without complications, stratification of patients presenting with possible
GABHS may result in significant morbidity in select pa- GABHS. McIsaac et al. adapted the score in 1998,
tients (6–10). Additionally, there are several diseases adding age as the fifth component (22). The modified
that mimic this condition and are essential for the Centor criteria underwent subsequent validation in both
emergency physician to consider when evaluating this 2000 and 2004 (Table 1) (23,24). Importantly, a score
common presentation. >4 points is associated with 51–53% likelihood of
GABHS infection (12,20,23–27).
DISCUSSION While most guidelines recommend that patients with
primarily viral symptoms and score < 1 do not require
Pharyngitis may be due to a myriad of causes (2,8,10). further testing, recommendations vary with respect to
The most common etiology is direct inflammation of the higher scores (Table 2) (3,12,14,21). Both the Infectious
oropharynx by an infection, which is caused by a viral Diseases Society of America (IDSA) and the American
source in the majority of cases (3–5,11–16). Despite Heart Association/American Academy of Pediatrics
this, up to 60% of patients managed in U.S. ambulatory guidelines recommend no empiric antibiotics on clinical
care clinics received antibiotics for a sore throat (11). scoring alone due to the risk of antibiotic overuse
GABHS is less common but is a frequent concern (12,15). The Centers for Disease Control and
among patients when requesting antibiotics. GABHS is Prevention/American Academy of Family Physicians/
spread through respiratory droplets and predominantly American College of Physicians guidelines state that
affects pa-tients aged 5–15 years (8,9). Infections occur antibiotics can be considered empirically for patients
most commonly in late winter to spring (8,9). In the with scores >3, while the European Society of Clinical
absence of host immunologic response to the organism, Microbiology and Infectious Diseases guidelines
GABHS can reside in the oropharynx without recommend performing the rapid antigen detection test
symptoms and, in this setting, the individual is (RADT) for patients with scores >3 (13,14).
considered a carrier. Up to 20% of asymptomatic Several testing options are available. The most
school-aged children are carriers, which increases to commonly used method is RADT, which can be per-
25% if household contacts are positive for GABHS formed using latex agglutination, enzyme immunoassay,
(16,17). or optical immunoassay techniques. Among the three
Because other etiologies may present similarly, the his- options, the enzyme and optical immunoassay tests
tory and physical examination are not definitive for the
diagnosis of GABHS pharyngitis. Symptoms of GABHS
pharyngitis can include sore throat, odynophagia, tonsillar Table 1. Modified Centor Criteria
exudates, tender cervical adenopathy, and fever (3,8,9,16).
Alternatively, cough, conjunctivitis, coryza, diarrhea, and Feature Score
skin exanthem are more frequent with viral pharyngitis Fever +1
(8,9,16). Symptoms of GABHS pharyngitis typically No cough +1
Anterior cervical lymphadenopathy +1
resolve within 2–5 days, while viral infections last longer Tonsillar exudate +1
(3,8,9,16). Examination may reveal erythema and exudates Age 3–14 y 1
along the posterior pharynx. Trismus, uvular deviation, and Age 15–44 y 0
submental lymphadenopathy should be absent, and their Age >44 y 1
presence suggests an alternate etiology (15,16,18). Score Range for GABHS
Cervical lymphadenopathy is commonly present in the Infection Risk, %
anterior neck, and skin inspection may reveal a diffuse, 0 1–2.5
erythematous rash. Suppurative complications can include 1 5–10
sinusitis, acute otitis media (AOM), retropharyngeal 2 11–17
3 28–35
abscess (RPA), and peritonsillar abscess (PTA), while >4 51–53
nonsuppurative complications include acute rheumatic
fever and glomerulonephritis (12–16,19). GABHS = Group A b-hemolytic Streptococcus.
Clinical Mimics of Streptococcal Pharyngitis 3

Table 2. Guidelines Summary for Pharyngitis

Centor Score AHA/AAP IDSA CDC/AAFP/ACP ESCMID

0–1 No test/treatment No test/treatment No test/treatment No test/treatment

2 Test (RADT) Test (RADT) Test (RADT) No test/treatment
3 Test (RADT) Test (RADT) Test or treat empirically Test (RADT)
>4 Test (RADT) Test (RADT) Test or treat empirically Test (RADT)

AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; ACP = American College of Physicians;
AHA = American Heart Association; CDC = Centers for Disease Control and Prevention; ESCMID = European Society of Clinical
Micro-biology and Infectious Diseases; IDSA = Infectious Disease Society of America; RADT = rapid antigen detection test.

have greater sensitivity (3,15,28–31). In pediatric glomerulonephritis (3,12–15,38). Evidence for the
patients, the sensitivity of RADT ranges from 86% to prevention of rheumatic fever was based on studies
88%, with a specificity of 86–92% (3,15,28–31). In from the 1950s, with an initial NNT of 50–60 to prevent
adults, the sensitivity ranges from 86% to 91%, with a rheumatic fever with antibiotics (41–44).
specificity of 86–97% (15,28–31). Therefore, if the test Approximately 1 of 3 patients with rheumatic fever will
result is positive, antibiotics are recommended. If develop rheumatic heart disease (45,46). In developed
negative in adults, no antibiotics or further testing is nations, rheumatic fever and rheumatic heart disease are
needed, with several caveats. Adults with rare, occurring at a rate of 1 case per million adults due
immunocompromised state, history of rheumatic fever, to improved hygiene and sanitation and alterations in
or exposure to an immunocompromised patient should the serotypes of GABHS that cause streptococcal
be tested with throat culture (3,12–15). If the RADT is pharyngitis (36,47–49). Given the low incidence, it is
negative in pediatric patients, it is recommended that a important to engage in shared decision making with the
throat culture also be performed due to the higher patient or parent regarding risks and benefits. Studies
pretest probability for infection (3,12,13,16). While have found that >80% of patients desire information
throat culture is 95% sensitive and 99% specific for concerning the infection and symptom improvement,
diagnosis, testing typically requires 24–48 hours for while only 38% desire antibiotic prescription (50–52).
culture growth (3,12,32). Culture should be obtained in Shared decision making is recommended in discussion
several patient populations, including those at high risk of risks and benefits of antibiotics. A potential script is
for severe infection and complications (e.g., ‘‘I understand you are experiencing pain due to your
immunocompromised, chronic steroids, and poorly infection. Over the counter medications such as
controlled diabetes) (3,12). DNA probe testing has also ibuprofen and acetaminophen, as well as throat
demonstrated high sensitivity (95%) and specificity lozenges, can improve your pain. Antibiotics can reduce
(100%), though the use of this test was found to change your symptoms by 12–16 hours, but they likely do not
management in only 3% of patients (33,34). Test results reduce the risk of rheumatic fever or heart disease.
are reported within 24 h for the DNA probe (32,33). Antibiotics can also cause a number of side effects,
Treatment with antibiotics for GABHS pharyngitis including allergic reactions and diarrhea.’’
focuses on reducing symptoms and suppurative compli-
cations (Table 3) (12–15,35–38). Pharyngitis from Another important aspect of treatment is symptom
GABHS is often self-limited. However, antibiotics have relief (Table 3). This may be initiated with either oral
been found to reduce symptoms by 12–16 h when analgesics or topical therapies. Acetaminophen and
compared to placebo (38). Additionally, antibiotics may nonsteroidal anti-inflammatory drugs (NSAIDs) are
reduce suppurative complications (e.g., otitis media,
sinusitis, and peritonsillar abscess) (38,39). Importantly, Table 3. Approach to Suspected Streptococcal Pharyngitis
the number needed to treat (NNT) is large for most of
these complications. The NNT to prevent PTA was 1. Evaluate airway, breathing, and circulation
found to be 28 in one study, while it ranged from 55 to 2. Consider alternate diagnoses and treat accordingly (Table 4)
3. Calculate Modified Centor Score
225 in another study (39). For AOM, the NNT was 25 4. Consider RADT, empiric treatment, or no further
in one study and >200 in a different study (39). Another testing depending upon clinical criteria
recent study found a suppurative complication rate of 5. Treat pain with oral analgesics (acetaminophen, NSAIDs,
or steroids) and topical anesthetics
1.3%, with no difference in the antibiotic group (40). 6. Discuss risks and benefits of antibiotics with patient or
Nonsuppurative complications include glomerulone- guardian
phritis and rheumatic fever. Several studies have
NSAID = nonsteroidal anti-inflammatory drug; RADT = rapid
demon-strated that antibiotics do not reduce the risk of antigen detection test.
4 M. Gottlieb et al.

beneficial for pain reduction, with improvement occur- Epiglottitis

ring within several hours (53–59). One study found that
ibuprofen 400 mg orally can reduce pain by 80% within Epiglottitis is inflammation of the supraglottic
4 h (53). Importantly, aspirin should be avoided in structures, including the epiglottis, which may result in
pediatric patients due to the risk of Reye’s syndrome airway obstruction and death without treatment (72–74).
(12). Topical anesthetic medications (e.g., benzocaine or Epiglottitis most commonly results from epithelial
lidocaine lozenges) also assist with pain reduction and infection and cellulitis of the epiglottis, aryepiglottic
have a faster time to pain relief than oral analgesics (60– folds, and surrounding tissues (72–76). Due to the large,
68). Corticosteroids are another treatment option for associated lymphatic and vascular network, infection
symptom reduction in pharyngitis (bacterial and viral), can easily spread to the supraglottic area, significantly
although IDSA guidelines recommend against routine decreasing the size of the airway caliber. The epiglottis
use (12). While not devoid of side effects, a recent itself will also swell, worsening the obstruction.
Cochrane review found that steroids were able to Haemophilus influenzae type b was the most common
significantly reduce pain with an NNT of 4 etiology in pediatric patients, though other bacteria,
(57,58,69,70). A systematic review published in 2017 such as Streptococcus and Staphylococcus, are
found that patients with viral or bacterial pharyngitis increasing (72–78). In adults, Streptococcal species are
who received steroids were twice as likely to have pain most common (76–79). Other causes include thermal
relief at 24 h and 1.5 times more likely to have complete injury, foreign-body ingestion, or caustic ingestion (72–
pain reduction at 48 h (71). Steroids reduce pain 77). Initial symptoms include throat pain and fullness.
severity and shorten the time to pain relief, though this Stridor, retractions, tachypnea, and cyanosis may not
systematic review did not find a reduction in symp-tom appear until later in the disease course and can occur
recurrence or relapse or missed days from work/ school rapidly in children. However, in adults, symptoms are
(71). A single dose of steroids in the ED is un-likely to often slower in onset due to the larger airway caliber.
cause a serious adverse event, with included randomized Pediatric patients present in acute distress and will
trials in this systematic review reporting no major choose to sit in a tripod or sniffing position in order to
adverse events (71). The most common steroid provided increase their airway caliber. Drooling and difficulty
is dexamethasone, given as 8–12 mg via oral or with tolerating secretions are also often present, though
intravenous route (57,58,69–71). This review coughing is rare. Symptoms occur within 24 h with
recommends using steroids in those with severe pain, sudden-onset fever, children demonstrate difficulty
trismus, or difficulty swallowing with no breathing in 80%, stridor in 80%, muffled/hoarse voice
contraindications to therapy. However, multiple steroid in 79%, pharyngitis in 73%, fever in 57%, sore throat in
doses are not recommended. 50%, and anterior neck tenderness in 38% (72,73,77).
Adults will present with odynophagia and sore throat in
Strep Throat Mimics 90–100% of cases, fever in 26–90%, muffled voice in
50–80%, drooling in 15–65%, and stridor in 33% of
Mimics of GABHS pharyngitis should be suspected if cases (76–79). Examination may reveal a normal
patients demonstrate signs of upper airway obstruction, pharynx (72–74,76). However, if the patient is in
trismus, tongue protrusion, dysphagia due to distress, immediate measures are required to protect the
obstruction, neck redness, inability to tolerate airway (72–74,76). A lateral radiograph of the soft
secretions, or voice changes (Table 4). These findings tissues of the neck can suggest the diagnosis if the
on history or physical examination strongly suggest epiglottis is thickened (i.e., ‘‘thumb sign’’) or the
another etiology for the patient’s symptoms. vallecula is not visible (73,79–81). However,
radiographs should not be relied upon to exclude the
diagnosis. Bedside ultrasound may also assist in
diagnosis with demonstration of an ‘‘alphabet P sign,’’
Table 4. Common Streptococcal Pharyngitis Infectious
Mimics which is the acoustic shadow of the epiglottis and hyoid
bone in the longitudinal orientation, or increased
Epiglottitis anteroposterior epiglottis diameter, though further study
Infectious mononucleosis
Kawasaki disease is required (82,83). Anesthesiology and otolaryngology
Acute retroviral syndrome should be consulted for awake intubation and possible
Lemierre’s syndrome tracheostomy in the operating room (73,77,81,84–87).
Ludwig’s angina
Peritonsillar abscess Antibiotics should include a combination of
Retropharyngeal abscess vancomycin 20 mg/kg i.v. with either ceftriaxone 2 g
Viral pharyngitis i.v, ampicillin/sulbactam 3 g i.v., or levofloxacin
Clinical Mimics of Streptococcal Pharyngitis 5

750 mg i.v. (72,73,76,84–86). Glucocorticoids are antibodies are not diagnostic in isolation, and it is
controversial. While some studies have demonstrated important to correlate the results with the patient’s
decreased inflammation and edema, they were not found symptoms. Approximately 10% of infectious
to reduce intubation rates, duration of mechanical mononucleosis cases are not caused by EBV (110,111).
ventilation, or duration of hospitalization (87–89). Other viruses that may cause infectious mononucleosis
Nebulized epinephrine may be considered as a include human immunodeficiency virus (HIV),
temporizing measure to reduce airway edema toxoplasmosis, herpesvirus, and cytomegalovirus
(72,73,76). Patients require admission to an intensive (110,111). If suspecting mononucleosis due to EBV,
care setting. clinicians should utilize clinical signs and symptoms with
white blood cell count and monospot test. If the monospot
Infectious Mononucleosis test is positive, symptomatic treatment is warranted (100).
If the monospot is negative but the clini-cian suspects
Mononucleosis is a constellation of fever, pharyngitis, mononucleosis due to EBV, the monospot test can be
and lymphadenopathy, most commonly caused by infec- repeated at a later date (100). Symptomatic treatment is
tion with the Epstein-Barr virus (EBV) (90–92). EBV is recommended with acetaminophen or NSAIDs (100).
widely disseminated, with up to 95% of adults found to Corticosteroids are controversial for symptom
be seropositive (90,91). The virus is typically acquired improvement (100,102,103,112). Studies have suggested
during childhood and is often subclinical, with < 10% of that a combination of acyclovir and prednisolone may
people demonstrating overt disease. However, if a reduce oropharyngeal virus shedding (100,102,112–114).
patient acquires the virus in adolescence and adulthood, However, they have not been found to reduce the duration
symptoms are commonly more severe (93,94). of symptoms (100,102,112–114). Patients should be
Transmission occurs through salivary secretions, which counseled on the importance of rest and avoiding contact
can include either direct contact (e.g., kissing) or sports for the first 2–3 weeks of symptoms (100,102–106).
indirect contact (e.g., sharing a glass of liquid). The
virus is most transmissible during the acute infectious
stage (90–93). However, EBV may occur after the Kawasaki Disease
infection has resolved and continues to be shed
intermittently for decades after the initial illness (93– Kawasaki disease is one of the most common forms of
96). Infection is life-long, as the virus becomes latent vasculitis in pediatric patients, but is rare in adults (115–
after primary infection (95,96). EBV replicates in 117). When Kawasaki disease is discovered in an adult
epithelial cells of the oropharynx, subsequently population, >25% have concomitant HIV (118). The
spreading to B cells in the lymphoid areas (95–97). vasculitis is typically self-limited, characterized by
Symptoms commonly include fever, sore throat, and fever and findings of inflammation that last for up to 12
lymphadenopathy (90–92). Palatine petechiae days if treatment is not initiated (115,116,119,120).
demonstrate a positive likelihood ratio (+LR) of 5.3, Diagnosis includes fever for more than 5 days with four
posterior cervical lymphadenopathy has a +LR of 3.1, of the following: nonexudative bilateral conjunctivitis
splenomegaly has a +LR of 1.9–6.6, and atypical (>75%), polymorphous rash (70–90%), extremity
lymphocytes >10% on a complete blood count has a erythema or edema (50–85%), cervical
+LR of 11 (98). Posterior lymphadenopathy, tonsillar lymphadenopathy (25–70%), and erythema of the lips
ex-udates, and splenomegaly are significantly correlated and oral mucosa (90%) (116,119–124). Patients often
with positive monospot test, while the absence of these experience a prodrome of respiratory and
three suggests an alternate etiology for the patient’s gastrointestinal symptoms, and they may experience
symptoms (98,99). Fever is found in 98% of primary sore throat. However, exudative pharyngitis is not
infections, along with pharyngitis in 85% (100,101). commonly found in Kawasaki disease and suggests
Lymph node enlargement is often posterior and another condition (119–124). Fever may not respond to
symmetric (98–102). Splenomegaly is found in 50–60% treatment, remaining >38.5 C despite antipyretics
of patients after 14 days of symptoms, and patients are (123,124). Incomplete Kawasaki disease is defined by
at significant risk for splenic rupture (102–106). less than four signs, though fever is still typically
Importantly, almost half of all ruptures occur without present (115,123,124). Infants may not demonstrate
trauma (105,106). fever, or they may have fever for longer than 1 week as
The monospot test utilizes latex agglutination and is the only clinical finding (115,116). Approximately 30%
85% sensitive and 100% specific for the presence of of patients may present with coronary artery dilatation
reactive heterophile antibodies in the patient’s blood at the time of diagnosis (125,126). Aneurysms do not
(99,100,107–109). However, reactive heterophile occur until after 10 days of infection (115,116).
6 M. Gottlieb et al.

Arthritis occurs in up to 25% of cases (127). Laboratory pneumonia or the presence of multiple pulmonary infarcts
findings may include an elevated C-reactive protein or in the context of a patient with a sore throat is strongly
erythrocyte sedimentation rate, thrombocytosis, normo- suggestive of this illness (135–138). When the diagnosis is
cytic anemia, pyuria, and elevated transaminases suspected, blood cultures should be obtained, assessing for
(115,120,123,124). Patients should receive an the presence of Fusobacterium necrophorum, which is seen
echocardiogram to evaluate cardiac function and for the in 70–80% of cases (135,136). Contrast-enhanced CT is
development of coronary aneurysms (115,120,123). the modality of choice for identifying internal jugular vein
Delayed diagnosis increases the risk of coronary thrombosis (137,139). However, ultrasound has been
aneurysm fivefold. Treatment includes intravenous suggested as an initial screening modality to assess for
immunoglobulin (IVIG) given as 2 g/kg over 8–12 h thrombosis due to the reduced radiation exposure
(115,116,123,128,129). Aspirin should be given in high (133,134). Treatment options include high-dose penicillin
doses (80 mg/kg/d). Glucocorticoids may be given to and metronidazole or mono-therapy with clindamycin,
patients with disease refractory to IVIG (116,120,123). along with coverage for methicillin-resistant
Staphylococcus aureus until culture results return (136–
Acute Retroviral Syndrome 138). Treatment with anticoagulation is controversial, and
decisions should be made in conjunction with the admitting
Early HIV infection may cause acute retroviral team (136–138).
syndrome with fever or chills (90%), fatigue (70–90%),
pharyngitis (>70%), rash (40–80%), headache (30– Ludwig’s Angina
70%), and gener-alized lymphadenopathy (40–70%)
(130–132). This complication typically occurs within Ludwig’s angina is a severe, rapidly progressive,
the first 2–3 months of HIV infection, and patients will necrotizing infection of the submandibular, submental,
generally have very high viral loads, reaching millions and sublingual spaces (140–143). Most cases are
of copies per milliliter of blood (130,131,133,134). odontogenic in etiology, primarily resulting from
Close to 70% of patients develop symptoms during the infections of the second and third molars (140–143).
acute phase (130,131). Patients with these symptoms for Patients may present with fever, pain, elevation of the
more than 7 days or risk factors for HIV warrant serum tongue, neck swelling, dysphagia, or odynophagia (140–
testing for HIV. When acute retroviral syndrome is 143). Involvement of the submandibular, submental,
suspected, rapid antigen testing is recommended over and sublingual spaces contributes to the risk of airway
the standard enzyme-linked immunosorbent antibody compromise in Ludwig’s angina. On examination, the
assay because antibodies can take 3–8 weeks to become submandibular area is often swollen and indurated
positive (130–133). Viral load testing is also possible. If (140–143). Crepitus may also be present (143). While
HIV testing is positive, consultation with infectious the diagnosis is often made clinically, CT may be
disease is recommended, as well as initiation of highly obtained in stable patients or those with a defini-tive
active antiretroviral therapy (130–134). airway in place (141,142). Early infections may be
treated with broad-spectrum antibiotics, otolaryngology
Lemierre’s Syndrome consultation, and intensive care unit admission to
monitor for airway compromise (141–143). Steroids
Lemierre’s syndrome is a rare disease of the head and have also been suggested to reduce the associated
neck, which most commonly affects young, adolescent inflammation and edema (144,145). More severe cases
males (135–138). Typically, an infection begins in the may require emergent fiberoptic intubation or
oropharynx and spreads to the retropharyngeal and tracheostomy due to airway compromise (142,143).
parapharyngeal spaces, followed by thrombosis of the
internal jugular vein and risk of septic emboli (135– Peritonsillar Abscess
137). Early in the course of the illness, patients
commonly present with a combination of fever, Peritonsillar abscess is a collection of purulent material
odynophagia, pharyngeal erythema, tonsillar exudates, located between the tonsillar capsule and posterior
cervical lymphadenopathy, and oropharyngeal ulcers pharyngeal muscles (146,147). Patients may present
(135–138). However, as the disease progresses, patients with fever, dysphagia, odynophagia, throat fullness,
may develop cranial nerve palsies, Horner syndrome, voice change, trismus, or inability to tolerate oral
trismus, jaw swelling, or systemic signs suggestive of secretions (146,147). On examination, patients can have
septic emboli (135–138). Involvement of the posterior trismus and unilateral peritonsillar swelling with
compartment of the neck can result in cranial nerve X– deviation of the tonsils and uvula (146). Tonsillar
XII palsy or Horner syndrome (137,138). Multifocal exudates may also be present, as many cases arise from
Clinical Mimics of Streptococcal Pharyngitis 7

tonsillitis (146). Often, the diagnosis may be made clini- exudates, and anterior cervical lymphadenopathy. His-
cally (146). However, CT and ultrasound may assist tory and physical examination are often insufficient for
with diagnosis and determining likelihood of successful the diagnosis. Clinical evaluation and use of scores can
aspiration (146). Ultrasound may also be utilized to help risk stratify patients for subsequent testing or treat-
facil-itate real-time drainage (148). Treatment involves ment. Antibiotics may reduce symptom duration and
pain control, antibiotics, steroids, and surgical drainage sup-purative complications, but the effect size is small
(146,149). Neither needle aspiration nor incision and with a large number needed to treat. Rheumatic fever is
drainage has demonstrated superiority to the other for uncom-mon in developed countries, and physicians
treatment of peritonsillar abscess (150). should engage in shared decision making if antibiotics
are to be used for this indication. Oral analgesics,
RPA steroids, and topical anesthetics should be considered
for symptom management. Physicians must consider
RPA is a suppurative, deep-space infection of the neck, alternate diagno-ses that may mimic GABHS
occurring in the potential space between the posterior pharyngitis, which can include epiglottitis, infectious
pharyngeal wall and prevertebral fascia (147). RPA oc-curs mononucleosis, Kawasaki disease, acute retroviral
more commonly in children than adults, usually after an syndrome, Lemierre’s syndrome, Ludwig’s angina,
upper respiratory infection, but the disease may also occur peritonsillar abscess, retropharyngeal abscess, and viral
by direct inoculation after oropharyngeal trauma or pharyngitis. A focused history and physical examination
procedures (e.g., laryngoscopy, endoscopy, dental pro- can help differentiate these conditions.
cedures) (147,151,152). While patients will often complain
of fever and odynophagia, symptoms can also include neck
stiffness, torticollis, trismus, voice change, or inability to
tolerate oral secretions (147,151–153). On physical
examination, patients will be ill-appearing and may
demonstrate evidence of neck stiffness or bulging of the
posterior pharyngeal wall (147,151–153). Lateral neck
radiographs may demonstrate widening of the
retropharyngeal space (147). However, CT with intra-
venous contrast may be preferable due to the ability to
differentiate RPA from retropharyngeal cellulitis and
should be considered in cases with significant swelling or
when patients worsen despite antibiotics (147). Most
infections are polymicrobial, and patients require broad-
spectrum antibiotics and otolaryngology consult for
possible surgical drainage (152,153).

Viral Pharyngitis

While not as dangerous as the medical conditions

already mentioned, it is important to differentiate viral
pharyn-gitis from streptococcal pharyngitis, as the
former does not require antibiotic therapy (9,154–156).
While patients may present similarly, viral pharyngitis
is more commonly associated with conjunctivitis,
coryza, cough, and diarrhea (9,154,156). Often, no
additional testing is necessary, though an influenza test
may be considered in certain contexts (16,156).
Treatment is predominantly supportive with hydration
and NSAIDs (154,156).

CONCLUSIONS

GABHS pharyngitis is a common presentation to the ED.

Patients often present with fever, sore throat, tonsillar