Sore Throat in Children – Clinical Considerations and Evaluation

INTRODUCTION TO THE CLINICAL PROBLEM:

A sore throat is usually a symptom of an infective process. It refers to a painful problem of the child, usually in the pharynx and often begins as a swallowing complaint. A sore throat can occur in all age groups, but in less than 2 years of age the cause is most likely viral. Sore throat though may not originate in the pharynx but can be associated with disease problems such as esophagitis or other surrounding area abnormalities. These have to be considered in the workup of the sick child with a sore throat. The greatest incidence of the problem occurs in the 5-18 year range, the cause being mainly bacterial, spread via respiratory droplets and secretions, with an incubation period of 2-5 days.

While parents are often worried primarily about the implications of streptococcal infection (strep throat) when their child has a sore throat, there are also many viruses that cause infections that behave very similar to strep. A child that has a sore throat with fever and a red, swollen throat or tonsils with white pus on them should have a throat swab taken for streptococcal infection:

If the tests are positive, the primary treatment is penicillin therapy for group A beta-hemolytic streptococcal pharyngitis (GABHS)
If the tests are negative, then the child’s throat infection is likely caused by a virus and antibiotics are not indicated, unless a second bacterial infection has become established.

Viral infections of the throat usually improve in three to five days without treatment.

Can you tell if a child’s throat has a strep infection just by looking at it? … No!

TEACHING POINT: Experience has shown that doctors and other health professionals are correct about half the time when they think a child has strep after just a physical exam. If the child is treated with antibiotics every time he/she is suspected to have a strep throat, then he/she would be overtreated or mistreated.

WHAT ARE THE COMMON CAUSES OF SORE THROAT?:

“Commonest things are commonest”:

Viral pharyngitis: Viruses that cause sore throat include the common cold virus, other upper respiratory tract viruses, adenovirus (which can also cause pinkeye at the same time), and others. If the child has purulent tonsils and the strep test is negative, then he/she probably has a viral infection.

Streptococcal Pharyngitis: caused by the bacteria group A streptococci. It is most common in children over three years old and begins with a fever, a red, swollen throat and tonsils that can have a white coating of pus, swollen glands, decreased appetite and energy level. If strep throat is suspected as the cause of tonsillitis in the child, a throat swab will confirm if there is infection with streptoccocus bacteria. This infection is easily treated with antibiotics, usually penicillin. The child will no longer be contagious after being on an antibiotic for 24 hours. It is important to take a complete course of antibiotics to prevent the child from getting rheumatic fever.

Less common:

Infectious Mononucleosis: a common illness usually caused by the Epstein-Barr virus (EBV). It typically infects teenagers and young adults, but also occurs in younger children, who have a much milder illness that is often not recognized as mono. Symptoms of mono consist of a high fever, sore throat, swollen tonsils with pus on them, fatigue, an enlarged spleen, and swollen glands that may be tender.

Herpangina: usually caused by the Coxsackie virus, causing painful blisters in the back of the child’s throat.

Gingivostomatitis: caused by a herpes virus, which can also cause blisters in the mouth.

Other less common but severe infections often progressing to pharyngeal swelling, or abscess formation, even approaching surgical emergencies:

Epiglotitis
Retropharyngeal abscesses
Lateral Pharyngeal abscesses
Peritonsillar abscesses

Least common:

These conditions are usually associated with high fever, drooling, severe pain and difficult breathing. Urgent evaluation and treatment is required:

Pediatric epiglotitis
Tracheitis
Diphtheria
Lemierre’s Syndrome – mixed anaerobic infection with septic emboli from jugular venous thrombosis.
Unusual infections – N. Gonorrhea, tularemia, mycoplasma, chlamydia, herpes
Even foreign bodies lodged in the throat – bone, sharp objects, etc.

Rarer causes to be considered:

Kawasaki disease
Stevens–Johnson syndrome
Behcet’s syndrome
Chemical exposure or burn
Referred pain – dental abscesses, cervical adenitis, otitis media
Immunosuppressed host with yeast superinfections, chronic antibiotic treatments

IMPLICATIONS OF STREP THROAT IN CHILDREN:

TEACHING POINT: It is important to understand the serious implications of this more common infective cause of pharyngitis, which when diagnosed properly can be treated easily and successfully thus avoiding the possible life long sequelae which the toxins of group A beta-hemolytic streptococci can cause.

Scarlet Fever in Children

Scarlet fever in children is a contagious infective illness characterized by sore throat, swollen painful tonsils and associated lymph nodes of the neck. It may be accompanied by a rough red rash in about 10% of cases, with sandpaper-like consistency. The illness is caused by a group A beta-hemolytic streptococcal infection of the upper respiratory passages manifesting a sore throat and upper airway symptoms. The serious part of the illness is the liberation of an exotoxin by the organism, capable of causing localized bullae (bullous impetigo), a systemic rash, or even a more serious lethal illness termed streptococcal toxic shock syndrome. Similar scarlet fever symptoms and signs can follow a streptococcal infection elsewhere, such as skin, soft tissue or surgical wound complications.

Rheumatic heart disease

Rheumatic heart disease is the most serious complication of scarlet fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death. If not recognized and treated properly, the end result of strep throat can become chronic rheumatic heart disease, with valve stenosis, atrial dilation, arrhythmias, and ventricular dysfunction. Chronic rheumatic heart disease, as a sequelae of scarlet fever, or strep throat, remains the leading cause of mitral valve stenosis and valve replacement in adults. Other rheumatic illnesses such as joint and soft tissue pain and swelling can occur. Neurologic changes can occur such as acute and chronic Sydenham’s chorea, often called St. Vitus’ dance, characterized by jerky incoordinate movements. This neuromuscular illness can be immediate or latent and usually occurs in the younger age group.

Glomerulonephritis

Acute glomerulonephritis refers to a specific set of renal diseases as a result of a hemolytic group A-beta hemolytic streptococcal infection in which an immunologic mechanism triggers inflammation and proliferation of renal tissue leading to damage of the glomerular basement membrane, mesangium, or capillary endothelium. Historically this disease of children was called Bright’s disease and was characterized by profound peripheral oedema, renal failure, heart failure and often death. Dropsy was another term used to describe the oedematous condition. In streptococcal infection, a streptococcal neuramidase may alter host immunoglobulin G (IgG). IgG then combines with host antibodies forming IgG/anti-IgG immune complexes which precipitate and block the glomeruli. Elevations of antibody titers to other antigens, such as antistreptolysin O or antihyaluronidase, DNase-B, and streptokinase, provide evidence of a recent streptococcal infection.

Some other antigenic illnesses confused as strep throat:

Hand-foot-and-mouth disease (HFMD) is a not uncommon viral illness with a distinct clinical presentation of oral and characteristic distal extremity lesions. Most commonly, the etiologic agents are Coxsackie viruses, members of the enterovirus family, namely enterovirus 71 (not related to the animal foot and mouth disease which is a different virus not involved in human disease). HFMD can manifest with high fever, paralysis even meningitis. The oral lesions may give rise to symptoms that are confused with strep throat but the small and scattered oral ulcerated lesions along with the peripheral cutaneous findings differentiate it from pharyngitis. An uncommon disease although it can give rise to large epidemics.

Infectious Mononucleosis (IM) is a common viral illness that can cause a persistent sore throat and fever. Usually seen in older young people, often occurring in dormitory living, it can present as a typical clinical syndrome in children – sore throat, fever, listlessness and on examination, splenomegaly. IM represents the immunopathologic expression that occurs under a specific set of circumstances and in response to infection with the Epstein-Barr virus. Following exposure, EBV infects epithelial cells of the oropharynx and salivary glands. B lymphocytes may become infected through exposure to these cells or may be directly infected in the tonsillar crypts. B-cell infection allows viral entry into the bloodstream, which systemically spreads the infection.

TEACHING POINT: In order to understand the clinical approach to history taking and examination of a child who has a sore throat, a differential diagnosis must be held in mind when approaching the problem. In a situation of a sore throat, the infective organisms must be considered also. The questions asked concerning the condition and the focus of the examination and investigation then makes more sense.

TAKING THE HISTORY – COMPLAINTS AND DURATION (symptoms):

How long has the sore throat been present? Rapid or slower onset? Are there associated colds or coughs? Is there discoloured sputum? Has there been ear ache or runny nose? Has there been a fever? Has anyone else in the family had sore throat recently? Is the immunization schedule up to date? Are there known allergies? Are there other illness factors – fatigue, medications, immunosuppression, social problems, sexual abuse?

EXAMINATION FINDINGS – WHAT TO LOOK FOR (signs):

examine for fever, fast pulse, difficult painful breathing and swallowing
swollen, tender cervical lymph nodes
oral mucosal ulcers, blisters
swollen purulent tonsils, evidence of foreign body? fishbone?
red, painful pharynx
nasal stuffiness, ear drums
stridor, drooling, wheezing
oral health, dental exam
complete chest examination necessary

CLINICAL FINDINGS:

	Bacterial	Viral
Fever	> 39.5 ºC	absent or present
WBC	< 5 or > 15	5 – 15
Discharge, nasal or throat	Pus (thick, dark yellow, orange or colour)	clear or light yellow, runny
Seasonal	–	+
Petechiae	+	–
Gram stain / culture	Blood, sputum, urinalysis	viral swab

TEACHING POINT: The history and physical examination will usually lead to the diagnosis but there are laboratory examinations that will be needed for diagnostic aid and for follow-up care.

LABORATORY – GRAM STAIN AND CULTURE:

	Bacterial (~ 30% of cases)	Viral (~ 40% of cases)
Common	GABHSStaphylococcus aureus(Moraxella)Branhamella ~~~catarrhalisBacteroides fragilis Bacteroides oralis Bacteroides melaninogenicus Fusobacterium species Peptostreptococcus species Haemophilus influenzae	RhinovirusAdenovirusParainfluenza virusCoxsackie virus Coronavirus Echovirus Herpes simplex virus Epstein-Barr virus ~~~(mononucleosis) Cytomegalovirus
Uncommon	Group C streptococciGroup G streptococciNeiseria gonorrhoeaeChlamydia trachomatis Mycoplasma pneumoniae
Rare	Corynebacterium diphtheriae
Extremely rare	Corynebacterium hemolyticum

No pathogen isolated: ~ 30% of cases

Principle of Management

Symptomatic relief
Antibiotic choice dependent on culture, sensitivity and any drug allergies in the child
Urgent or emergency care depending on degree of respiratory symptoms

Click here for: Clinical Pathways in Managing sore throat in Children