1. GABHS. Patient presents with fever, sore throat, and tender cervical adenopathy. Headache, nausea, vomiting, and abdominal pain are common. Marked erythema of throat is present, with hyperemic, exudative tonsils and palatal petechi-ae. Nasal congestion and rhinorrhea is usually absent. More common in late winter and early spring.

2. Epstein-Barr virus (EBV). Can cause severe exudative pharyngitis with fever, palatal petechiae, posterior cervical lym-phadenopathy, periorbital edema, and splenomegaly. Coinfection with GABHS is common.

3. Adenovirus. Commonly causes exudative pharyngitis or pharyngoconjunctival fever. Ipsilateral preauricular adenopathy is a helpful clue to diagnosis.

4. Coxsackievirus. Typically occurs in summer and early fall. Causes herpangina with multiple small vesicles on tonsils and soft palate. Coxsackievirus A16 causes so-called hand-foot-mouth disease, characterized by small ulcers on tongue and buccal mucosa, and vesicles on hands, feet, and occasionally buttocks.

5. Herpes simplex virus (HSV). Can cause pharyngitis with fever and lymphadenopathy or severe gingivostomatitis in young children.

6. Other causes. The most common viral cause of pharyngitis is rhinovirus (approximately 20%). Coronavirus, influenza, parainfluenza, and cytomegalovirus are other viral causes. Patients with HIV acute retroviral syndrome often present with sore throat, fever, lymphadenopathy, lethargy, and nonexuda-tive tonsillitis. Other bacterial causes include mycoplasma, Neisseria gonorrhea, and Chlamydia pneumoniae.

B. Retropharyngeal Abscess. Insidious onset of fever, dysphagia, and neck stiffness follows mild upper respiratory infection. Signs of upper airway obstruction may be present if abscess is compressing trachea. Most common in children younger than 2 years (50%); rare in children older than 5 years (because retropharyn-geal nodes involute).

C. Lateral Neck or Parapharyngeal Abscess. Occurs in later childhood; patient presents with fever, throat pain, and trismus if anterior compartment is involved. Posterior compartment contains cranial nerves IX through XII, carotid artery, and cervical sympathetic trunk. Infection in this area, although uncommon, can affect all of these structures.

D. Peritonsillar Abscess. The most common deep neck infection in children. Occurs in older children and younger adolescents. Initial presentation is fever and sore throat followed by gradual onset of dysphagia, dysphonia ("hot-potato" voice), drooling, and unilateral focus to the pain. Trismus (due to an inflamed pterygoid muscle) is often present and may be a helpful clue. Uvula deviates to contralateral side.

E. Epiglottitis. Has become rare since development of Hib vaccine. Patient presents with fairly rapid onset of fever, sore throat, odynophagia, and drooling, which progresses to respiratory distress from upper airway obstruction. Most common in children between ages 2 and 6 years.

F. Bacterial Tracheitis. Rapid onset of high fever, worsening stridor, and respiratory distress following viral laryngotracheitis. Usually caused by Staphylococcus aureus. Most common in children between ages 4 and 6 years.

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