Introduction

Pain at the back of the mouth
Encompasses acute pharyngitis and tonsilitis
- Acute pharyngitis: Inflammation of the oropharynx
- Tonsilitis: inflammation of the tonsils

Aetiology

70% viral (Adenovirus, enterovirus, rhinovirus)
10-30% bacterial; mostly Streptococcus pyogens (aka Group A Beta Haemolytic Streptococcus aka GAS)
- carriers in 1-5% esp. in children

Pharyngeal and soft palate inflammation and/or haemorrhage seen
Local lymph node enlargement and tender
Difficult to swallow or eat
Generalised non-specific symptoms: Fever, headache, nausea, vomiting, and abdominal pain

Acute Group A streptococcal (GAS) pharyngitis/tonsillitis is common in children and adolescents aged 5 to 15 years and is more common in the winter (or early spring) in temperate climates
Important to distinguish between bacterial vs viral cause of sore throat as bacterial infection can cause complication (see below)
Suspect bacterial infection if: fever >38, tonsillar/pharyngeal exudate, anterior neck lymphadenopathy, and absence of cough
if GAS needs to be confirmed (in vulnerable group) then arrange a rapid antigen test
Centor/Fever-PAIN can be used to determine the likelihood of GAS

Two scoring systems exist to determine the likelihood of streptococcal infection

Centor scoring
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever (over 38°C)
- Absence of cough

0-2= No antibiotics; 3-4= Antibiotics

0-1= No antibiotics; 2-3= Consider a back-up antibiotic prescription; 4-5= Antibiotics

Casued by Strep pyogenes pharyngitis; 5-16 yrs old upto 30 yrs old; symptom start 2 weeks later
High risk of rheumatic fever: previous history of rheumatic fever, South African, Australian indigenous communities, Maori communities of New Zealand, the Philippines, and other developing countries, extreme of ages,
Major manifestation: arthritis (flitting polyarthritis, larger joints), carditis, chorea, rash (erythema marginatum), nodules
Minor: Fever, previous episode, raised ESR/CRP, ECG abnormalities, arthralgia
Aschoff bodies in heart (10% carditis), prolonged P-R interval, murmurs
Diagnosis: throat swab, anti-streptolysin O titre, ECHO

Caused by Strep pyogenes pharyngitis or skin infection; 1-5 yrs old; occurs 10-14 days after infection
Abrupt fever, malaise, loin pain, oedema of feet and face, haematuria and proteinuria, oliguria
Impaired renal function
Almost always resolves without specific treatment
Immune complexes in glomerular basement membrane

Mostly secondary to pharyngitis due to erythrogenic toxin A,B or C (Streptococal pyrogenic Exotoxins) → 10% of GAS produce these toxins
Incubation 2-4 days
Sudden onset of fever; rash follows 12-48 hours later (face, neck, trunk –“sandpaper” texture
Often pallor around the mouth
Skin desquamation

If viral cause suspected, then advice self-care
Hospital admission if
- Systematically unwell
- Peri-tonsillar abscess or cellulitis, parapharyngeal abscess, retropharyngeal abscess, or Lemierre syndrome
Give Antibiotics based on Centor or Fever-PAIN score
- 1st line: Phenoxymethylpenicillin
- 2nd line: Clarithromycin or Erythromycin (preferred in Pregnant)
- Low threshold for antibiotic treatment in people with high risk of Rheumatic fever, vulnerable people including extreme of ages, immunosuppressed or immunocompromised
AVOID amoxicillin (can cause maculopapular rash if tonsilitis caused by EBV i.e. glandular fever)