Pharyngitis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

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Overview

Pharyngitis should be differentiated from other infectious causes which mimic sore throat that includes oral thrush, infectious mononucleosis, epiglottitis and peritonsilar abscess.

Differentiating Pharyngitis from other Diseases

The major goal of the differentiating patients with sore throat or acute pharyngitis is to exclude potentially dangerous causes (e.g. Group A streptococcus), to identify any treatable causes, and to improve symptoms. Identifying the treatable causes is important because timely treatment with antibiotics helps prevent complications such as acute rheumatic fever, post streptococcal glomerulonephritis.

Thrush	Mononucleosis	Epiglottitis	Peritonsillar abscess
Thrush is caused by candidal infection Dysphagia without odynophagia which will differentiate it from pharyngitis. White plaques that reveal an erythematous base when scraped Usually in immunocompromised patients, including those with advanced HIV/AIDS	Mononucleosisis caused by infection with Epstein-Barr virus Usually, it presents with a classic triad of severe sore throat accompanied by fever and lymphadenopathy Other symptoms and signs include the following: Fatigue Diffuse lymphadenopathy, particularly bilateral and posterior cervical Splenomegaly in 50% of cases Hepatomegaly in 10% of cases Pharyngeal petechiae Rash: 90% of patients will develop a pruritic, maculopapular rash after the use of ampicillin or amoxicillin	Epiglottitis is an inflammation of the epiglottis and adjacent structures that can be life-threatening caused by Hemophilus influenzae especially unimmunized children. In adults, epiglottitis has widely varying presentations and symptoms: Odynophagia (most commonly) Fever, toxicity Dyspnea, respiratory distress Dysphagia Drooling Dysphonia Inspiratory stridor The classic tripod positioning (patient sits or stands leaning forward and supporting the upper body with hands on the knees), is seen only in 5% of cases If epiglottitis is suspected, immediate referral to the emergency department for airway management Diagnosis requires laryngoscopy If the patient is in respiratory distress, prompt intubation is required to maintain airway.	Peritonsillar abscess is the collection of pus behind the tonsil in the superior arch of the soft palate It might develop as a complication of oropharyngeal infection, such as tonsillitis The most common bacteria is group A streptococci, but the causative organism could be polymicrobial Symptoms include fever, malaise, dysphagia, drooling, muffled or 'hot potato' voice, and referred ear pain. Diagnosis is a combination of physical examination and imaging with computed tomography (CT) or ultrasonography Management requires urgent referral to a specialist or surgeon for surgical drainage, in addition to antibiotic treatment.

Variable	Pharyngitis	Oral thrush	Mononucleosis	Epiglottitis	Tonsilitis	Retropharyngeal abscess
Presentation	Sore throat, Pain on swallowing,  fever,  headache Abdominal pain,  nausea andvomiting	Dysphagia without odynophagia which will differentiate it from pharyngitis.	Usually presents with a classic triad of severe sore throat fever lymphadenopathy	Usually present with stridor and drooling; and other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice	Sore throat, pain on swallowing, fever, headache, cough	Neck pain, stiff neck, torticollis fever, malaise, stridor, and barking cough
Causes	Group A beta-hemolytic streptococcus.	candidal infection	Epstein-Barr virus	H. influenza type b, beta-hemolytic streptococci, Staphylococcus aureus, fungi and viruses.	Most common cause is viral including adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus. Second most common causes are bacterial; Group A streptococcal bacteria,[5]	Polymicrobial infection. Mostly; Streptococcus pyogenes, Staphylococcus aureus and respiratory anaerobes (e.g. Fusobacteria, Prevotella, and Veillonella species)[6][7][8][9][10][11]
Physical exams findings	Inflammed pharynx with or without exudate	White plaques that reveal an erythematous base when scraped	Diffuse lymphadenopathy, particularly bilateral and posterior cervical,Splenomegaly in 50% of cases, Hepatomegaly in 10% of cases, Pharyngeal petechiae, Rash in 90% of patients will develop a pruritic, maculopapular rash after the use of ampicillin or amoxicillin	Cyanosis, Cervicallymphadenopathy, Inflammed epiglottis	Fever, especially 100°F or higher.[17][18]Erythema, edema and Exudate of the tonsils.[19] cervical lymphadenopathy, Dysphonia.[20]	Child may be unable to open the mouth widely. May have enlarged cervical lymph nodes and neck mass.
Age commonly affected	Mostly in children and young adults, with 50% of cases identified between the ages of 5 to 24 years.[23]	Usually in immunocompromised patients, including those with advanced HIV/AIDS	Common in adolescents between 15-25	Used to be mostly found in pediatric age group between 3 to 5 years, however, recent trend favors adults as most commonly affected individuals[22] with a mean age of 44.94 years.	Primarily affects children between 5 and 15 years old.[24]	Mostly between 2-4 years, but can occur in other age groups.[25][26]
Imaging finding	—	—	—	Thumbprint sign on neck x-ray	Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[27][28][29]	On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen[30][31]
Treatment	Antimicrobial therapy mainly penicillin-based and analgesics.	oral fluconazole	Supportive therapy Glucocorticoids may be indicated in such cases of severe airway obstruction.	Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[32][33]	Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases.	Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin.