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When Sore Throats Hurt!

By Scott Hamilton, MD
May 26, 2022
Hamilton Blog Headshot Updated 12.21.21

This week’s guest columnists are Marie Baker, MD and Chris Clark MD, family practice residents at Ochsner University Hospital & Clinics.

4 year old boys are usually active dudes. Running around, yelling and laughing, settling down only to watch TV and slug down some macaroni. Unfortunately, this changed for one squirt I saw in the Pediatric ER at Ochsner Lafayette General Medical Center. Mom reported after his head hit the pillow at bedtime, he was moaning, restless and hot. The next morning his fever continued, he stayed on the couch and ate little. When I examined him, his throat was covered with red polka dots. The Strep throat test was positive.

We see lots of sore throats in the emergency department. They’re usually accompanied by more viral symptoms: coughs and runny noses. Littler kids don’t mention sore throats, often not having the words yet to tell about their throat pain. Teenagers are a different story, how terrible is their pain! So excruciating that they are almost distracted from texting while being examined. Must. Stop. My. Eyes. From. Rolling.

Telling the difference between viral sore throats and the bacterial one (Streptococcus Pyogenes, the culprit in Strep throat) is important. The viral infections get better on their own; Strep throat requires an antibiotic to get better and prevent complications. You can’t always tell by looking. Viral sore throats can hurt as much, cause fever and can be just as red as Strep. And not all Strep throat cases have the classic findings: the red polka dots, the white coated “strawberry” tongue, headaches and upset stomach. It takes testing to know. If it’s negative, antibiotics won’t help and giving them “just in case” or because “it looks like Strep and sometimes the test is falsely negative” is poor practice.

Why is Mononucleosis, or “Mono” for short, called the kissing disease? It started with research by Willam S. Evans, an epidemiologist at Yale University. His work established that infectious Mononucleosis was transmitted mainly through kissing. What’s missing from history is how he conducted these experiments, where known carriers of the culprit, Epstein-Barr virus, transmitted it to uninfected people. We can only imagine: “Subject 46, you may now kiss Subject 72, for a duration of 10 seconds. Proceed.”

Mononucleosis is common among kids and adolescents, mostly causing throat infections. Besides Epstein-Barr virus, several other viruses look the same: sore throat, fatigue, headaches, swollen lymph glands in the neck and fevers. Sounds like the Strep throat we discussed last week, right?

There are important differences between Strep throat and Mono. First, Mono is a virus and thus antibiotics don’t cure it. Your immune system gets rid of viruses by itself. Unfortunately, Mono can last a week or more. That’s a long time with painful throat and fatigue. When kids are sick for that long, we worry something worse is going on, so we do tests to be sure. There’s a blood test for Mono, but you have to be sick for about 7 days for it to turn positive. When Strep throat tests are negative, practitioners need to NOT prescribe antibiotics, no matter how long the patient’s sick- they just won’t help and can even hurt!

Patience and pain meds are the solution: Acetaminophen and Ibuprofen, in proper doses. In some bad cases, we prescribe Prednisone, which is a steroid. Steroids are anti-inflammatory medications and can help with throat swelling. One last caution for Mono: no contact sports that may impact the abdomen. Mono causes swelling of the spleen, a blood-filled organ that can rupture when smacked.