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An Unusual Sore Throat

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 27-year-old man with a history of pharyngeal gonorrhea presented with a 7-day history of severe sore throat and odynophagia, worse when swallowing solids than liquids. Owing to the odynophagia, he had presented to the emergency department for dehydration. At that time, he was febrile to 101°F and denied any dysphonia or dyspnea. The results of a rapid Streptococcus test, recent HIV screen, and a rapid plasma reagin test were all negative. He denied any genital lesions or symptoms at that time. He had been taking prophylactic emtricitabine-tenofovir daily and had received his last diphtheria booster 2 years prior to presentation. Treatment with amoxicillin clavulanate over several days had not prevented a worsening of his symptoms. On physical examination, there was no cervical lymphadenopathy, and there were no genital lesions. Flexible fiber-optic nasopharyngoscopy showed ulcerative lesions with exudate and erythema extending diffusely along the base of tongue, oropharynx, nasopharynx, hypopharynx, and epiglottis (Figure 1).

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C. HSV-2 pharyngitis

The patient underwent HIV, rapid plasma reagin, monospot, HSV-1, an HSV-2 blood tests. Oropharyngeal cultures were taken for bacteria, fungus, and gonorrhea/chlamydia. Results of a qualitative polymerase chain reaction assay performed on a tissue swab were positive for HSV-2 and negative for HSV-1. Screening detected HSV-1/HSV-2 IgM serum antibody, and IgG serum antibody findings were indeterminate, suggesting current or recent infection. All other laboratory and culture findings were negative; therefore, a diagnosis of HSV-2 pharyngitis was made. He subsequently began treatment with valacyclovir, 3 g/d. No exudates or lesions were noted on physical examination nor on flexible fiber-optic nasopharyngoscopy at his 2-week follow-up visit (Figure 2). At that time, he was no longer complaining of odynophagia.

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Article Information

Corresponding Author: William K. Karle, MD, Department of Otolaryngology–Head & Neck Surgery, Oregon Health and Science University (OHSU), Physician’s Pavilion 250/PV01, Northwest Clinic for Voice and Swallowing, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (karle@ohsu.edu).

Published Online: May 2, 2019. doi:10.1001/jamaoto.2019.0612

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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