• Synonym(s): sore throat; tonsillitis; “strep throat”
  • Acute or chronic inflammation of the pharyngeal mucosa and underlying structures of the throat
  • Group A Streptococcus (GAS) pharyngitis is notable for preventable suppurative (e.g., retropharyngeal or peritonsillar abscess) and nonsuppurative (e.g., rheumatic sequelae) complications.


  • ~15 million cases are diagnosed yearly.
  • Accounts for 1–2% of all outpatient visits and 6% of all pediatric visits to primary care physicians
  • Most commonly viral (40–60% of cases)
  • GAS is the most common bacterial cause of acute pharyngitis, accounting for 15–30% of pediatric cases (with peak incidence in 5- to 11-year-olds) and 5–15% of adult cases. The incubation period ranges from 24 to 72 hours.
  • Less common causes of pharyngitis includes Fusobacterium necrophorum, nongroup A (group C or G) Streptococcus, and, if sexually active, Neisseria gonorrhoeae
  • Rheumatic fever is a serious sequelae but is rare in the United States (<1 case per 100,000). Early antibiotic use has diminished occurrence.
  • 3,000 to 4,000 patients with group A β-hemolytic streptococcal infection must be treated to prevent one case of acute rheumatic fever.

Pediatric Considerations
The highest incidence of rheumatic fever is in children aged 5 to 18 years as a rare sequela of streptococcal pharyngitis.

Etiology and Pathophysiology

  • Acute, viral (associated with lower grade fever)
    • Rhinovirus; adenovirus (associated with conjunctivitis); parainfluenza virus; coxsackievirus (hand-foot-and-mouth disease); coronavirus; echovirus
    • Herpes simplex virus (vesicular lesions); Epstein-Barr virus (EBV; mononucleosis); cytomegalovirus (CMV)
    • HIV
  • Acute, bacterial (associated with higher fevers)
    • Group A β-hemolytic streptococcus
    • N. gonorrhoeae; Corynebacterium diphtheriae (diphtheria); Haemophilus influenzae
    • Moraxella catarrhalis; Chlamydia pneumonia
    • F. necrophorum (20% young adult cases); group C or G Streptococcus
    • Arcanobacterium haemolyticum; Mycoplasma pneumoniae; Francisella tularensis (tularemia)
  • Acute, noninfectious
    • Various caustic, mechanical, or trauma-related (including endotracheal intubation)
  • Chronic, more likely noninfectious
    • Chemical irritation (GERD)
    • Smoking
    • Neoplasms
    • Vasculitis
    • Radiation changes

Patients with a family history of rheumatic fever have a higher risk of rheumatic sequelae following an untreated group A β-hemolytic streptococcal infection.

Risk Factors

  • Epidemics of group A β-hemolytic streptococcal disease
  • Cold and flu season (late fall through early spring)
  • Age (rheumatic fever possible, especially in children/adolescents aged 5 to 15 years)
  • Close contact with infected individuals (home, daycare, military barracks)
  • Immunosuppression
  • Smoking/secondhand smoke exposure
  • Acid reflux
  • Oral sex
  • Diabetes mellitus
  • Recent illness (secondary postviral bacterial infection)
  • Chronic colonization of bacteria in tonsils/adenoids

General Prevention

  • Avoid close contact with infectious patients.
  • Wash hands frequently.
  • Avoid firsthand or secondhand smoke.
  • Manage preventable causes (e.g., GERD).

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