Also known as “Pharyngitis” (“-itis” for infection or inflammation, the former in this case since we’re dealing with germs). It’s one of my favorite topics, because it’s so common, & yet has so many interesting subtleties about diagnosis, which so many seasoned clinicians fail to appreciate. We’ll delve into lots of fascinating information, & conclude with a manageable summary.
Here we’ll discuss a Sore Throat that’s been going on for 3 Days or less. See also our following topic Sore Throat: Going on 4-5 days or Longer — Full Text.
During the pandemic, if we hear “sore throat,” we think “Covid”. Every office & clinic has its own way of testing for it, & won’t let the patient inside. One Covid-Negative test isn’t 100%, although a second negative 2 days later likely would be. Unfortunately, every site that does Covid tests has different turn-around times; sometimes results are back in 30 minutes, others may take a week!
Clinicians address Sore Throat depending on how long a patient’s been sick. That’s because within 3 days, simple viruses turn into obvious Common Colds (runny nose, etc.), and Strep Throat gets better on its own. Here’s our (ridiculously complete) Table:
Causes of Sore Throat (Pharyngitis)
|xxxxxxFIRST 1-3 DAYS||xxxLASTING 4-5 DAYS OR MORE|
|xxxxxMost Common Causes|
• Common Simple Viruses
• Strep Throat
xxxxxxWe Send to E.R. (very rare)
• Peritonsillar Abscess *
• Deep Tissue Infection **
• Diphtheria **
• Neutropenia **
• Tularemia **
• Rabies **
xxxxxxWe Should Never Forget
• Acute (Primary) HIV
* Life-threatening, & uncommon
** Life-threatening & very rare
|• Strep Throat [unlikely after 3 days]|
• Acute (Primary) HIV
• Herpes simplex ?
• Syphilis (secondary stage)
• Don’t Miss These” (see 1st Column)
• Allergic Rhinopharyngitis (“allergies”)
• Gastroesophageal Reflux (GERD)
During the first 3 days of Sore Throat, the only diseases we consider are:
Let’s start with this last category first, because it caught your attention. They include a variety of very rare deep mouth & throat bacterial infections like Epiglottitis, Retropharyngeal Abscess, Peritonsillar Abscess, Ludwig’s Angina, Lemierre syndrome, & others. Nothing’s subtle about them — the patient has a high fever, looks terrible, & often can’t even open their mouth. All of them need IV antibiotics, & oftentimes surgery.
We send such patients right to an E.R. We NEVER try to examine the throat (an accidental gag could close it off & kill them). If the person is so ill that they’re leaning bent forward drooling, or struggling to breathe, we call 911. Search Google images if you like gross pictures. Also, we can’t simply send such patients off for a Covid test; as such, whoever is screening patients at an entrance needs enough training to call for a health professional able to assess patients who simply look ill.
Actually, someone with an early Peritonsillar Abscess may not be that ill. Feverish & sick, but not such an extreme. They would probably get penicillin anyway, but should ask their examiner if their “uvula is deviated,” or if the “soft palate is swollen on one side.” These signs are subtle enough to miss if the clinician doesn’t specifically think about them. See Pictures 2 and 3.
We’re not talking “tonsillitis,” but rather a surrounding abscess. Penicillin might work (in higher doses than usual), but some patients will need to have the abscess drained in an ER if they don’t quickly improve.
Other very rare but life-threatening causes of sore throat include:
** Diphtheria — We’d only think of this if the person had returned from a poor part of the world or the former Soviet Union within the last 5 days, & we saw a grayish membrane in the throat. See Picture 4.
** Neutropenia — This means “very low White Blood Cell (WBC) count.” It causes large ulcers or blisters in the throat (not tiny blisters in the mouth, commonly due to certain viruses). The danger is that if the WBCs are too low, there’s a risk of life-threatening blood infections.
Neutropenia can be due to Leukemia, but is often caused by certain medicines like those for hyperthyroidism (not thyroid hormone for hypothyroidism), or clozapine for schizophrenia. Anyone who prescribes these always warns patients to seek care if they get a sore throat.
** Acute (Primary) HIV Infection — Up to 80% of people who were just infected with HIV develop an acute illness 9-30 days later. Most have fever and tender lymph nodes (“swollen glands”); 75% may have a sore throat. Symptoms last 1-3 weeks & go away on their own. AIDS develops an average of 8 years later.
I never used to worry about Acute HIV until a sore throat had gone on at least 5 days, by which time most common sore throats are over & done. There’s obviously plenty of time to diagnose and treat HIV, and I’d go nuts addressing this for every patient who sought care with a “sore throat for 2 days.” But now I worry more, because our “ill-for-2-days” patient may come for care this one time only, and missing Acute HIV has major consequences:
- An estimated 50% of all HIV transmission is due to Acute HIV, when patients carry enormous amounts of virus. This level of virus may persist 4 months. So even though the sore throat gets better, and was never contagious orally, people are out and around infecting others through sex.
- If our Acute HIV patient was unlucky enough to have been infected with a drug-resistant viral strain, it’s best identified as early as possible. If they get diagnosed a few years later, the test for drug-resistance may not show it. Treat HIV with a wrong drug, & the virus becomes resistant to even more medications.
W discuss Acute HIV more under Sore Throat — Going on 4-5 Days or More. But even at the very beginning of a sore throat, I may mention it & urge certain patients to return if symptoms last a few more days. These cases include:
- People with major risk factors for having gotten HIV in the last 2-4 weeks.
- Presence of tender lymph nodes in atypical locations, like behind the ears, back of neck, back of head (not under the jawbone, where they’re common).
- A funny rash, often subtle, not itchy, usually on the abdomen or back, maybe elsewhere.
Common Causes of Sore Throat
Now, assuming Covid tests are negative, we’ll go on to the 2 most common causes of Sore Throat that’s only been going on a few days.
** Common Viruses — Around 90% of sore throats are caused by common viruses (see Differences Among Germs). There’s nothing to do for them, they get better on their own, antibiotics don’t help. We can tell it’s a virus because: 1) there’s no reason to suspect a life-threatening infection; and also 2) there’s nothing to suggest Strep Throat (see below).
** Strep Throat (a.k.a. “Strep”) — Caused by the bacteria Streptococcus pyogenes, also called “Group A beta-hemolytic Strep” abbreviated GABHS. The “beta-hemolytic” just refers to a property in the lab’s Petri dish. Sore throat from Strep also goes away on its own, so quickly in fact, that even though penicillin cures it, it’s hard to prove that the antibiotic helps anyone feel better faster.
The main danger of Strep Throat is that it can cause Rheumatic Fever, with permanent and serious heart damage, 3 or more weeks later. This happens in poor parts of the world, but is very rare nowadays in the US (except perhaps among immigrants, in poor urban areas, & past outbreaks in suburbs of Pittsburgh, Denver, Salt Lake City, & who knows where else as only 6 states & Washington DC have maintained mandatory reporting ever since the CDC dropped it in 1994).
Rheumatic Fever primarily affects children (50% are under 10-years-old). Even when the disease was more common (pre-1970), new occurrence over age 20 was unusual & over 30 unheard of. Treating Strep Throat within 9 days prevents Rheumatic Fever.
Current recommendations say to test for Strep Throat if 3-4 of the “Centor Criteria” are present:
- Pus on throat or tonsils (whitish “exudate”)
- Tender lymph nodes under the jaw
- NO cough or runny nose
Brief comment about “Exudate” — all that’s white isn’t pus. True “exudate” appears splotchy and “pasted-on.” People who’ve had tonsillitis in the past may have crater-like scars where gunk (old food) gets stuck; this isn’t pus. Most of the time, if a patient says they saw “white stuff in the throat,” I don’t find true exudate on exam. See Picture 1.
Testing for Strep — We have 2 methods: 1) Cultures, which take 24-48 hours to see if the germ grows in the lab; and 2) Rapid Tests (by antigen-detection), with results in a few minutes. The former is a little more accurate. If you’re really concerned about preventing Rheumatic Fever, ask to wait for the culture result. If you’re impatient & will risk a rare false-negative, go for the rapid test.
To get a good swab, the clinician has to rub the throat or tonsils vigorously with the cotton. We can’t just dab at it, which means we need a good sustained view. Best way is if the patient gives a good, long yawn, and doesn’t tilt their head back. Swabbing shouldn’t cause a gag if we’re careful to avoid the middle of the throat, & just aim for the sides.
Both culture and rapid-test can give false-positives, since around 10% of people may be colonized with Strep, meaning it just sits in our throat along with many other types of bacteria & doesn’t do anything. If you want to know 100% for sure if it’s Strep, a negative antibody (blood test) today & a positive one in 3-4 weeks proves it. We don’t do that, since it’s obviously of no practical use for the patient.
And why don’t we give everybody penicillin, just in case it’s strep? For one, there are occasional side effects. But most importantly, the more antibiotics get used, the easier it is for bacteria to become resistant to them. Then, when someone really needs medicine, it won’t work.
SUMMARY — Sore Throat 3 Days Or Less
An Adult patient has a Sore Throat for 1-2 days. Of course, we do a Covid test. Let’s say they don’t look very ill, we have no reason to suspect Primary HIV infection, and they never had rheumatic fever as a child. Well, we don’t need to do anything, because:
- They’ll recover no matter what pretty soon; treatment would barely reduce symptoms by a day or two at most
- They’re too old to get rheumatic fever
The only reasons we might test for Strep are: 1) So they won’t be angry at us; and 2) If they live with kids, treatment might prevent contagion (but might likely be too late anyway). So perhaps we order a rapid test if they have 3-4 of the Centor Criteria:
- Pus on throat or tonsils (“true exudate”)
- Tender lymph nodes in under the jaw
- NO cough or runny nose
For a Child under 15-20, we worry a little about rheumatic fever, even though it’s real rare [some experts say too rare to care, but I don’t agree]. So we decide whether or not to test by the Centor criteria, certainly if 3 are present, maybe even 2.
- A Rapid Strep Test gives an immediate answer, maybe 5% false-negatives
- A Culture is more accurate; if there are other kids at home, it might not be bad to give 2 days of penicillin while waiting for results (though nobody does this)
What I suggest my patients do if they get a sore throat?
- Get a Covid test. Shelter in place for a couple of days. If there’s a cough, and Covid is Negative, then get another one.
- If the sore throat turns into a runny nose, & you’ll know it’s a simple virus
- If 1-2 full days have gone by, the sore throat persists unchanged, there’s no cough or runny nose, AND there’s been a fever or swollen glands, get a test for Strep Throat
- If they’re very ill, high fever, can hardly open their mouth, they need to be seen (& should avoid anything that might cause gagging). If uncontrollable drooling, or trouble breathing, call 911.
See also Sore Throat for the clinician’s condensed thought-process when face-to-face with a patient.
For Sore Throat going on 4-5 Days or More, see that topic’s Full Text.