Sore Throat (Pharyngitis)

Causes

Viral - by far the most common cause (colds, flu, adenovirus, mononucleosis/EBV, COVID-19). Usually accompanied by cough, runny nose, hoarseness, or conjunctivitis.

Bacterial - most notably Streptococcus pyogenes (Group A Strep, "strep throat"), accounting for roughly 20-40% of pediatric cases and 5-15% of adult cases. Peak incidence is in children aged 5-15. Presents with abrupt-onset fever, pain on swallowing, and swollen submandibular lymph nodes, typically without cough or hoarseness. On exam: swollen uvula, enlarged tonsils, palatal petechiae, and a red pharynx with patchy or confluent white exudate (Goldman-Cecil Medicine, ch. 269).

Other causes: allergies, postnasal drip, dry/irritated air, acid reflux, smoking, and (rarely) peritonsillar abscess or epiglottitis.

Diagnosis: distinguishing viral from strep

Because clinical impression alone is correct only about 75% of the time even with classic findings, clinicians use the modified Centor score (age, tonsillar exudate, tender anterior cervical nodes, fever, absence of cough) to decide who needs a rapid strep test or throat culture. A score of 0-1 generally means testing/antibiotics can be skipped; higher scores warrant testing - Goldman-Cecil Medicine, p. 174-176.

Recent evidence note: A 2024 systematic review/meta-analysis (Kanagasabai et al., PMID 38182052) found the Centor and McIsaac scores have only moderate accuracy for predicting strep positivity in secondary-care settings, reinforcing that confirmatory testing (rapid antigen test or culture) remains preferred over clinical scoring alone. A 2025 pediatric meta-analysis (PMID 39331273) likewise found imperfect correlation between clinical findings and strep test positivity - so a clinician's exam should guide testing, not replace it.

Treatment

Viral sore throat: self-limited (3-6 days even for untreated strep, similar for most viral causes); manage with fluids, salt-water gargles, throat lozenges, warm liquids, humidified air, and analgesics/antipyretics (acetaminophen or ibuprofen). Antibiotics do not help.
Strep throat: treated with antibiotics (penicillin or amoxicillin first-line) both to shorten symptoms and, importantly, to prevent complications such as rheumatic fever, post-streptococcal glomerulonephritis, peritonsillar abscess, or (rarely) streptococcal toxic shock syndrome.

When to see a doctor (red flags)

Severe or worsening sore throat lasting more than a week
High fever (especially >101°F/38.3°C), especially with no cough/cold symptoms
Difficulty breathing or swallowing, drooling (in children), or a muffled "hot potato" voice
Pus/exudate on tonsils, rash, or swollen/tender neck glands
Blood in saliva or phlegm
Recurrent episodes

Most sore throats resolve on their own within a week regardless of cause; the main reason to seek care is to rule out strep or a more serious process (e.g., abscess, epiglottitis, mononucleosis) that needs specific treatment.

If you're dealing with a sore throat yourself right now and want guidance on your specific symptoms (duration, fever, other symptoms), let me know and I can help narrow down whether it sounds viral or warrants a strep test.

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