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would treat regardless of laboratory results When three of the four are present, laboratory sensitivity of rapid antigen testing exceeds 90% When only one criterion is present, GABHS is unlikely Sore throat may be severe, with odynophagia, tender adenopathy, and a scarlatiniform rash An elevated white count and left shift are also possible Hoarseness, cough, and coryza are not suggestive of this disease Marked lymphadenopathy and a shaggy white-purple tonsillar exudate, often extending into the nasopharynx, suggest mononucleosis, especially if present in a young adult Recently, the lymphocyte-white blood cell count ratio has been reported to efficiently and specifically differentiate tonsillitis from infectious mononucleosis With about 90% sensitivity, lymphocyte ratios of > 35% suggest EBV infection Hepatosplenomegaly and a positive heterophil agglutination test or elevated anti-EBV titer are corroborative However, about one-third of patients with infectious mononucleosis have secondary streptococcal tonsillitis, requiring treatment Ampicillin should routinely be avoided if mononucleosis is suspected because it induces a rash that might be misinterpreted by the patient as a penicillin allergy Diphtheria (extremely rare but described in the alcoholic population) presents with low-grade fever and an ill patient with a gray tonsillar pseudomembrane The most common pathogens other than group A hemolytic streptococci in the differential diagnosis of sore throat are viruses, Neisseria gonorrhoeae, Mycoplasma, and Chlamydia trachomatis Rhinorrhea and lack of exudate would suggest a virus, but in practice it is not possible to confidently distinguish viral upper respiratory infection from GABHS on clinical grounds alone Infections with Corynebacterium diphtheriae, anaerobic streptococci, and Corynebacterium haemolyticum (which responds better to erythromycin than penicillin) may also mimic pharyngitis due to group A -hemolytic streptococci

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Given the availability of many well-documented studies in recent years, one would think that a consensus might develop as to the most appropriate way to treat a sore throat The Infectious Diseases Society of America recommends laboratory confirmation of the clinical diagnosis by means of either throat culture or a rapid antigen detection test The American College of Physicians American Society of Internal Medicine (ACP-ASIM), in collaboration with the Centers for Disease Control and Prevention, advocates use of a clinical algorithm alone in lieu of microbiologic testing for confirmation of the diagnosis in adults for whom the suspicion of streptococcal infection is high Others examine the assumptions of the ACP-ASIM guideline for using a clinical algorithm alone and question whether those recommendations will achieve the stated objective of dramatically decreasing excess antibiotic use Convincing clinical trials as well as clinician reminders and patient-based interventions may be needed before clinicians are likely to abandon longheld teachings (even though different clinicians appear to have been taught different strategies) regarding diagnosis and management of group A streptococcal pharyngitis A Cochrane review concluded that multifaceted interventions

Colletti T et al Strep throat: guidelines for diagnosis and treatment JAAPA 2005 Sep;18(9):38 44 [PMID: 16184870] Schaad UB Acute streptococcal tonsillopharyngitis: a review of clinical efficacy and bacteriological eradication J Int Med Res 2004 Jan Feb;32(1):1 13 [PMID: 14997699] Tewfik TL et al Tonsillopharyngitis: clinical highlights J Otolaryngol 2005 Jun;34 Suppl 1:S45 9 [PMID: 16089240]

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