Photo Quiz

Empiric Treatment for Acute Pharyngitis


Am Fam Physician. 2019 Dec 1;100(11):713-714.

A 20-year-old woman presented with one week of fever and throat pain. She reported progressive difficulty in swallowing and had been unable to eat or drink for 48 hours. She did not have cough, rashes, or recent sick contacts. She was otherwise healthy with no pertinent medical conditions.

On physical examination, the patient had a temperature of 103°F (39.4°C) and bilateral tender anterior cervical lymphadenopathy. Oral examination revealed vesicular lesions over the soft palate and uvula, erythema of the posterior oropharynx, and tonsillar hypertrophy without exudate (Figure 1).




Based on the patient's history and physical examination findings, which one of the following is the most appropriate treatment option?

A. Dexamethasone.

B. Observation.

C. Oral acyclovir.

D. Intravenous acyclovir.

E. Penicillin V potassium.


The correct answer is D: intravenous acyclovir. Based on the history and examination findings, the patient was diagnosed with primary herpes simplex virus type 2 (HSV-2) infection. Traditionally, HSV-1 is implicated in oral and pharyngeal infections, and HSV-2 is implicated in genitoanal infections; however, these patterns have been blurred by evolving sexual practices.1 When HSV infection is suspected, polymerase chain reaction testing or viral culture of vesicular fluid and serum immunoglobulin G and M assays can aid in characterization. Testing for other sexually transmitted infections may also be indicated. The precise incidence of primary HSV pharyngitis is not well documented; however, a study of 613 college students with acute pharyngitis demonstrated a 5.7% prevalence of HSV, with all but two cases identified as HSV-1.2

Typically, primary HSV infections begin with a prodrome of nonspecific symptoms, including fever, headache, malaise, nausea, vomiting, and/or lymphadenopathy, with accompanying oropharyngeal erythema or petechiae, followed

Address correspondence to James D. Haddad, MD, FACP, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Balasubramaniam R, Kuperstein AS, Stoopler ET. Update on oral herpes virus infections. Dent Clin North Am. 2014;58(2):265–280....

2. McMillan JA, Weiner LB, Higgins AM, et al. Pharyngitis associated with herpes simplex virus in college students. Pediatr infect Dis J. 1993;12(4):280–284.

3. Spruance S, Aoki FY, Tyring S, et al. Short-course therapy for recurrent genital herpes and herpes labialis. J Fam Pract. 2007;56(1):30–36.

4. Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis [published correction appears in Am Fam Physician. 2017;95(7):414]. Am Fam Physician. 2016;94(1):24–31. Accessed October 14, 2019.

5. Hayward GN, Hay AD, Moore MV, et al. Effect of oral dexamethasone without immediate antibiotics vs placebo on acute sore throat in adults: a randomized clinical trial. JAMA. 2017;317(15):1535–1543.

6. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887.

7. Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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