Monospot Testing

In general, infectious mononucleosis caused by the Epstein-Barr virus (EBV) occurs most commonly in teenagers and young adults between the ages of 15 and 24 years. It can be very difficult to differentiate clinically presenting symptoms and signs from those of GABHS pharyngitis. A monospot blood test is often negative during the first 1-2 weeks of the illness, and a repeat test may be required if symptoms persist. EBV-specific antibodies to a number of viral antigens can be measured but may unavailable or require lengthy testing times, making them impractical in many clinic or emergency department settings. In general, serologic testing for evidence of mono­nucleosis is recommended in patients with splenomegaly, pharyngitis symptoms persisting for 5-7 days, or GABHS positive or suspected on initial visit treated with appropriate antibiotics and returning with persistent symptoms. ⁹

Making Patients With a “Sore Throat” Feel Better

The use of steroids to reduce symptoms in acute pharyngitis is controversial. Several studies have been performed regarding this issue; they are of mixed quality and were limited to immunocompetent patients.¹⁹ The key issue is that in all studies showing benefit, patients were also treated with antibiotics for documented or presumed GABHS infection. However, a single dose of dexamethasone, betamethasone, or prednisone appears to reduce symptom severity in undifferentiated acute pharyngitis in adults.²⁰ Data for children are less conclusive, with one study reporting modest early benefits in GABHS-positive patients. No significant differences in side effects or complications were found in meta-analyses.19 Onset to relief was at 6-9 hours with steroids vs. 12-18 hours for placebo, and for complete resolution within 24 hours the NNT was 4.²⁰ Studies in patients with infectious mononucleosis have shown benefit in symptom reduction in the first 12 hours, but this benefit appears to disappear at 2-4 days.²¹

For pain relief, effective short-term (less than 24 hours) alternative treatments include nonsteroidal anti-inflammatories and acetaminophen.²² One interesting and very practical finding is that nonmedication interventions—specifically, better doctor to patient communication—had an effect size compared with placebo as large as 93%. Increased courtesy, increase in consultation time from 6 to 10 minutes to discuss diagnosis and treatment plans, and offering a prognosis of when a patient should be feeling better were all cited.²² These may be especially important in patients not receiving antibiotics.

Finally, are there any other alternative treatments we can recommend to our patients? What about a good old-fashioned gargle with a warm salt solution? Many herbs and plant extracts have been promoted as beneficial for sore throats, but there is insufficient evidence to recommend any particular agent.²³