Sore Throat: Avoid Overcomplicating the Uncomplicated

TO THE EDITOR: Linder (1) discounts the possibility that Fusobacterium necrophorum causes pharyngitis and proposes that, even if it does, we should not assume that treating this condition would prevent suppurative complications (especially the Lemierre syndrome). He argues that we should stick to a simple strategy of using the Centor score to reassure some patients (those with scores of 0 or 1) and use a rapid streptococcus test for the remaining patients, treating only those with positive rapid test results. He asserts that we should not complicate the diagnosis and treatment decisions. We strongly disagree. Although preadolescent sore throat is relatively straightforward and the prevalence of F. necrophorum in these younger patients is clearly lower, the bacterial pathogenesis of adolescent and young adult pharyngitis is more complex. The highest-probability differential diagnosis in this age group includes group A -hemolytic streptococcus (Streptococcus pyogenes), group C or G -hemolytic streptococcus (Streptococcus dysgalactiae subsp equisimilis), infectious mononucleosis, acute HIV infection, and now F. necrophorum. Linder's recommendation is dangerous because it can lead to diagnostic errors through the anchoring bias. If our decision structure is binary (group A streptococcus or not), then we are at risk for missing a more serious infection. Our data suggest that the Centor criteria define a symptom complex for acute bacterial pharyngitis, with group A streptococcal infection being only 1 cause. The current empirical treatment algorithm based on the Centor criteria includes macrolides for patients with a history of penicillin allergy, and this class of antibiotics does not cover F. necrophorum. Treating Fusobacterium pharyngitis has a strong possibility of decreasing the likelihood of progression to the Lemierre syndrome. Although we cannot prove this assumption, its biological plausibility strongly supports this hypothesis. We have much evidence that F. necrophorum causes the pharyngitis. Several case reports have documented pharyngitis with Fusobacterium bacteremia (2). Our study (3) strongly supports the idea that F. necrophorum causes pharyngitis. As the Centor score increased, so did the probability of a positive polymerase chain reaction result for F. necrophorum. Although this finding does not absolutely prove that F. necrophorum causes pharyngitis, one has to develop a rather convoluted explanation to assert otherwise. Our concern about this topic relates to the devastation that the Lemierre syndrome causes. Having communicated with many survivors and the families of some patients who died of this condition, we feel passionately that the best approach to the Lemierre syndrome (like many other diseases) is prevention. As one of us pointed out several years ago, the incidence of the Lemierre syndrome developing after a sore throat now exceeds that of rheumatic fever in the United States and Europe (4). The argument against treating patients with Fusobacterium pharyngitis centers on the lack of proof. The absence of a diagnostic test at present for F. necrophorum does not negate the need to adjust the recommendations for empirical, criteria-based therapy predicated on the latest epidemiologic evidence. In the absence of definitive proof, we favor treating patients with a substantial probability of F. necrophorum pharyngitis with targeted antibiotics in the hope that we may prevent some patients from developing this devastating complication.