Sore throat is a common childhood complaint. Only otitis media, or ear infection, account for more visits to the physician's office. Sore throat may be attributed to viral, bacterial, or fungal infections. The majority of sore throats are related to viral upper respiratory infection. Descriptions of causal agents and clinical features of sore throat in children are summarized below.

Viral Pharyngitis

1. Adenovirus - Adenovirus is the most common cause of non-streptococcal pharyngitis in children and is seen in children of all ages. It occurs most frequently during the Fall, Winter, and Spring months. Clinical features include:

• Gradual, non-abrupt onset
• Low grade or absent fever
• Associated with rhinorrhea, nasal congestion, and/or cough
• Post-nasal discharge may be visualized
• General malaise
• Mild pharyngeal erythema
• Minimal tonsillar enlargement
• Tonsillar exudate (50%)

Treatment is supportive in nature, including warm saline gargles, acetaminophen for discomfort or fever, rest, and fluids. Children may attend school as long as they are sufficiently well to participate in school activities and are fever free.

2. Enteroviruses (coxsackie virus) - Herpangina is a viral disorder affecting the oral mucosa and the throat. The disorder is caused by the coxsackie virus A and is seen most often in infants and young children during the summer months. Clinical features include:

• Abupt onset of fever (may be high)
• Dysphagia occurring within 2-3 days after onset of the fever
• Sore throat
• Mild erythema of the tonsils
• Vesicles and/or ulcers on the anterior tonsillar pillars. May also be seen on the soft palate, tonsils, and uvula. The gingival and buccal mucosa is NOT involved. Involvement of these areas suggest herpes stomatitis. Papulovesicular lesions on the palms of the hands or soles of the feet suggest hand-foot-mouth disease

Treatment is supportive in nature Warm saline gargles, acetaminophen or ibuprofen for fever and/or discomfort, and fluids are suggested. The risk for dehydration exists for small children who refuse to drink. Children should be excluded from school until fever free for 24 hours.

3. Epstein-Barr virus. The Epstein-Barr virus causes infectious mononucleosis and other clinical disorders. 85% of children with mononucleosis develop pharyngitis and 33% may present with exudative tonsillitis and/or pharyngitis. In the early stages of this disease, the history and physical exam may be similar to that seen in streptococcal pharyngitis. Therefore, infectious mononucleosis should be considered in children whose clinical picture is similar to that of streptococcal pharyngitis but with a negative throat culture. Infectious mononucleosis occurs in children of all ages, but is most common in older school-age children, adolescents, and young adults. The disorder may be laboratory confirmed with a positive monospot test or heterophil antibody test after 7-10 days of illness (tests conducted before this time may be false-negative).Clinical manifestations include:

Early

Malaise

Low grade fever, gradual onset

Tonsillar erythema, enlargement, patchy gray exudate

Pharyngeal erythema

Palatal petechiae

Posterior cervical lymphadenopathy (nontender)

Abdominal pain

Nausea/vomiting/anorexia

Headache

Later (3-5days into the course of the disease)

Tonsillar exudate becomes more extensive

Pharyngeal edema

Posterior and anterior cervical lymphadenapathy (tender)

Inguinal and/or axillary lymphanopathy

Erythematous, maculopapular rash

Splenomegaly (70%)

Hepatomegaly (50%)

Treatment is supportive in nature. Acetaminophen for fever, fluids, and rest are recommended. The acute phase of the disorder lasts 1-2 weeks. Activity, including school attendance, is restricted as long as the child is febrile. Fatigue may persist for 4 weeks. Complete recovery may take 6 weeks. Frequent rest periods are encourage during this period. The child may return to school once fever free, however contact sports are contraindicated in those with spleen or liver enlargement. Concurrent streptococcal pharyngitis is treated with penicillin or erythromycin. Treatment with amoxicillin is contraindicated as allergic dermatitis occurs in 80% of those infected with Epstein-Barr virus who receive amoxicillin.

Bacterial Pharyngitis

1. Streptococcus pyogenes. Group A beta hemolytic streptococci (GABHS), the most prevalent substrain of streptococcus pyogenes, accounts for approximately 10% of all pharyngitis cases. However, the incidence of streptococcus pharyngitis is higher (20-40%) in the school-age and adolescent population. Streptococcal pharyngitis may occur throughout the year, but is most common during the Fall and Winter months. Cyclical outbreaks occur within the school population. The disorder is most commonly seen in children and young adults (age 2-21) and is uncommon in children younger than 2. Peak age of incidence is between the ages of 6-12. Clinical manifestations include:

• abrupt onset of sore throat (may be severe) without evidence of nasal congestion, rhinorrhea, or cough
• dysphagia
• tonsillar and pharyngeal edema
• tonsillar erythema (may be severe)
• tonsillar exudate (50-80%)
• anterior cervical lymphadenopathy (30-50%)
• fever >102F
• headache
• abdominal pain/nausea/vomiting
• erythematous, fine sand-paper rash on chest/abdomen (scarletinaform rash)

Streptococcal and viral sore throat may be difficult to differentiate based on clinical symptoms alone. It is therefore recommended that a throat culture is collected on all children with exudative pharyngitis. Treatment for GABHS pharyngitis is supportive (acetaminophen for fever & discomfort, fluids, and rest) in addition to antibiotic treatment. Penicillin, amoxicillin, or erythromycin (in the penicillin allergic child) are prescribed for 10 days.The child may return to school when fever free and after 24 hours of antibiotic therapy. Untreated GABHS may lead to otitis media, lymphadenitis, peritonsillar abscess, and acute rheumatic fever. Acute glomerulonephritis is a rare complication of GABHS infection regardless of adequate initial therapy.

2. Gonococcal Pharyngitis - Oral sex with another infected with neisseria gonorrhoeae may result in gonococcal pharyngitis. Gonococcal pharyngitis is usually very mild, however tonsilar enlargement, cervical lymphadenapathy, and exudate may be present. The disorder should be considered in sexually active adolescents or abused children who present with persistent sorethroat and/or exudative pharyngitis with a negative streptococcal culture. The diagnosis is confirmed by throat culture (a special transport medium is necessary, unless immediate inoculation of the medium is possible). Gonococcal pharyngitis is treated with IM ceftriaxone. The child should also be evaluated for other sexually transmitted diseases.