Margaret R. Hammerschlag

Children and young adults visit physicians for sore throats more often than for any other problem or symptom. Technically, pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the throat. Although the symptom of sore throat invariably is present with pharyngitis, it should not be used as the sole criterion for diagnosis. Sore throat can be a common complaint in children with colds when no evidence of pharyngeal inflammation is present.

Pharyngitis can be subdivided into two categories: illness with and illness without nasal symptoms. This division has important etiologic implications. Almost always, nasopharyngitis has a viral cause, whereas illness without nasal symptoms (pharyngitis or tonsillopharyngitis) can have diverse causative agents, including bacteria, viruses, and fungi (Table 248.1).


Most often, the etiologic agents involved in nasopharyngitis are viruses, with adenovirus types 7a, 9, 14, and 15 being the most common. Influenza, parainfluenza, and Epstein-Barr virus are the other major viral agents. Rhinovirus and respiratory syncytial virus infections are not often associated with objective pharyngeal findings.

Pharyngitis (including tonsillitis and tonsillopharyngitis) can be caused by a diversity of infectious agents, ranging from group A beta-hemolytic streptococci to more obscure agents, such as Corynebacterium diphtheriae and Francisella tularensis. As with other infections, the probability that any one agent is the cause of pharyngitis depends on the age and immune status of affected patients, the season, and the environment. In normal, healthy children, more than 90% of all cases of pharyngitis are caused by the following organisms, listed in order of decreasing frequency of occurrence: group A beta-hemolytic streptococci; adenoviruses; influenza viruses A and B; parainfluenza viruses 1, 2, and 3; Epstein-Barr virus; enteroviruses; and Mycoplasma pneumoniae. Pharyngitis and sore throat may be present also in 44% of patients with acute human immunodeficiency virus type 1 infection.

Other beta-hemolytic streptococci, especially groups C and G, have also been isolated from children and young adults with pharyngitis. Other, less common bacterial sources of pharyngitis include Arcanobacterium haemolyticum, formerly called C. hemolyticum. The genus Arcanobacterium currently includes six species. A. haemolyticum has also been isolated from chronic skin ulcers, soft tissue infections, and brain, peritonsillar, paravertebral, and intraabdominal abscesses. The organism has also been associated with pneumonia, sinusitis, and orbital cellulitis in children. A. haemolyticum has been identified in 0.5% to 9.3% of children and adolescents with pharyngitis in three studies from Canada, Greece, and Finland. In one study, 50% of the patients with A. haemolyticum also had group A streptococci isolated from their throat cultures. The organism has been found infrequently in individuals without pharyngitis. A study of Finnish army conscripts found A. haemolyticum in 0.4% of asymptomatic individuals. Children in the 15- to 18-year-old age group were most likely to be affected. Clinically, pharyngitis due to A. haemolyticum closely resembles that caused by group A beta-hemolytic streptococci, and a significant number of patients may also have a scarlatiniform rash. There are no population-based studies on the role of
A. haemolyticum in pharyngitis from the United States. Neisseria gonorrhoeae should be considered in adolescents who are sexually active or are known to have been exposed and possibly should be considered in abused children. Most abused children from whom N. gonorrhoeae has been isolated from the nasopharynx are asymptomatic.


Organism Percentage of Cases Associated Disorders or Symptoms
Group A streptococcus 5–20 Tonsillitis, scarlet fever, ARF
Beta-hemolytic streptococci group C or G 6 Tonsillitis, scarlatiniform rash
Neisseria gonorrhoeae Rare Tonsillitis
Arcanobacterium haemolyticum 0.5–9.3 Scarlatiniform rash
Corynebacterium diphtheriae Rare Diphtheria
Francisella tularensis Rare Tularemia (oropharyngeal form)
Adenovirus, types 7a, 9, 14, 15 19 Pharyngoconjunctival fever, acute respiratory disease including pneumonia
Epstein-Barr virus 7–15 Infectious mononucleosis
Rhinovirus ? Common cold
Coronavirus ? Common cold
Respiratory syncytial virus 1 Bronchiolitis, URI
Parainfluenza virus 5 Cold and croup
Coxsackie A ? Herpangina, hand-foot-and-mouth disease
Influenza A and B virus ? Influenza
Cytomegalovirus ? CMV mononucleosis
Herpes simplex virus types 1, 2 ? Gingivostomatitis
Human immunodeficiency virus ? Primary HIV infection
Mycoplasma pneumoniae 10–13 Pneumonia, bronchitis, otitis, erythema multiforme
Chlamydia pneumoniae ? Pneumonia
ARF, acute rheumatic fever; CMV, cytomegalovirus; HIV, human immunodeficiency virus; URI, upper respirator infection.

Among viral causes, adenovirus is the most prevalent. One study has found viruses to be responsible for 42% of all cases of pharyngitis in a group of children who were between ages 6 months and 17.9 years and who had acute exudative tonsillitis. Adenovirus was responsible for 19% of the cases, followed by Epstein-Barr virus. Two children (1.8%) had infections with herpes simplex virus, and five children had infections with M. pneumoniae.


Nasopharyngitis tends to be more common in younger children. The presentation can vary, depending on the agent. Usually, fever is present. Infection with adenovirus may be associated with conjunctivitis and exudative pharyngitis, whereas infection with influenza A or B frequently is associated with more severe systemic complaints. The onset of pharyngitis can be acute, with fever and the complaint of sore throat. Affected children also may have headache, nausea, vomiting, and, occasionally, abdominal pain. Usually, physical examination reveals moderate to severe pharyngeal erythema and tonsillar enlargement and varying degrees of cervical adenitis. The erythema can be associated with follicular, ulcerative, and petechial lesions and with areas of exudate. Follicular tonsillitis is fairly characteristic of adenoviral infections, and ulcerative lesions usually are observed with enteroviral infections. The presence of exudate has been thought in the past to be most common or characteristic of group A streptococcal infection or infectious mononucleosis. A prospective, 1-year study of acute febrile exudative tonsillitis, however, found that 42% of the cases had a viral cause, predominantly adenovirus. The only clinical clues to the nature of the infecting agent were cough and rhinitis, both of which were observed in 45% of patients with viral disease and in only 10% of children with beta-hemolytic streptococci. Pharyngitis in children is almost entirely acute and self-limited, lasting from 4 to 10 days, depending on the cause.

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Jul 24, 2016 | Posted by in ORTHOPEDIC | Comments Off on Pharyngitis

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