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An 18-year-old man has a 3-day history of rhinorrhea, sore throat, cough, fatigue, and malaise. He states that he has no fevers or chills. His medical history is unremarkable, and he has no allergies. He works in a social welfare office and has seen several clients with "colds" recently.
On physical examination, his temperature is 37.6°C. The posterior oropharynx is erythematous; however, no tonsillar exudate or cervical lymphadenopathy is present.
Which one of the following management approaches is most appropriate in this case?
A. No testing; prescribe azithromycin
B. A rapid antigen-detection test and throat culture; prescribe an antibiotic if either test is positive
C. Measurement of antistreptococcal antibodies (streptolysin O and DNase B); prescribe an antibiotic if positive
D. No testing; prescribe penicillin
E. No testing and no empiric treatment
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E. it looks like a case of viral pharyngitis. supportive treatment given
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E
does not meet the criteria for a strept throat...
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E is correct.
The appropriate approach to managing a young adult with pharyngitis, rhinorrhea, and a cough but no fever, tonsillar exudate, or cervical lymphadenopathy is reassurance. No diagnostic test or empiric treatment is needed.
In patients with pharyngitis, the 4-point Centor criteria are used to estimate the risk for group A streptococcal infection and to determine whether additional testing or treatment is indicated.
One point is given for each of the following criteria: fever, absence of cough, tender cervical lymphadenopathy, and tonsillar exudate. A score of 0 is associated with a risk for streptococcal infection that is less than 2.5%; a score of 3 or 4 is associated with risk of infection between 28% and 53%.
For patients with a score of 0 (as in this scenario), no testing or treatment is recommended. For patients who have a score ≥2, testing by rapid antigen-detection test and throat culture (and treating if positive) is recommended.
For patients with a score of 3 or 4, the guidelines about empiric treatment vary.
For diagnosed group A streptococcal pharyngitis, penicillin is the treatment of choice.
Azithromycin is an alternative for penicillin-allergic patients.
Antistreptococcal antibodies help support a diagnosis of acute rheumatic fever or poststreptococcal glomerulonephritis by confirming recent group A streptococcal infection, but these tests are not useful in establishing acute infection.
Source: NEJM
