Differential Diagnosis for Sore Throat and Fever

Primary Consideration: Viral Upper Respiratory Infection

The presence of cough strongly suggests a viral upper respiratory tract infection rather than bacterial pharyngitis, and testing or antibiotics are not indicated unless specific features suggest Group A Streptococcus or other serious bacterial infection, as recommended by the American College of Physicians 1
Viral URI is the most likely diagnosis when cough accompanies pharyngitis symptoms, as cough is highly suggestive of viral origin and uncommon in bacterial pharyngitis, according to the American Academy of Family Physicians 1
Common viral causes include rhinovirus, coronavirus, adenovirus, influenza virus, parainfluenza virus, respiratory syncytial virus, Epstein-Barr virus, and enteroviruses, as reported by the American Heart Association 3
The presence of cough, along with other respiratory symptoms, strongly suggests viral rather than streptococcal etiology, as stated by the Infectious Diseases Society of America 3

GAS pharyngitis typically presents WITHOUT cough—the absence of cough is actually part of the modified Centor criteria used to assess likelihood of streptococcal infection, according to the American College of Physicians 1
Suspicious features for GAS include: sudden-onset severe sore throat, tonsillopharyngeal exudates, tender anterior cervical adenopathy, fever, scarlatiniform rash, palatal petechiae, and swollen tonsils, as recommended by the American Academy of Pediatrics 3
Testing for GAS should NOT be performed when clinical features strongly suggest viral etiology (presence of cough, rhinorrhea, conjunctivitis, hoarseness, or diarrhea), as stated by the American College of Physicians 1

Influenza commonly presents with fever, headache, myalgias, and constitutional symptoms accompanied by respiratory symptoms including cough, according to the Centers for Disease Control and Prevention 1
COVID-19 presents with fever, cough, headache, sore throat, and malaise, and may include nasal congestion, runny nose, and systemic symptoms, as reported by the World Health Organization 5

The American College of Physicians recommends assessing for viral features (any present = likely viral), including cough, nasal congestion or rhinorrhea, conjunctivitis, hoarseness, and diarrhea 1
If viral features are present, no testing or antibiotics are needed, as stated by the American Academy of Family Physicians 1
If no viral features are present, apply Modified Centor Criteria for GAS, which include fever by history, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough, as recommended by the American Heart Association 3

For Viral URI, the American College of Physicians recommends no antibiotics, symptomatic treatment with analgesics, antipyretics, and supportive care, and expected duration of 5-7 days, which may persist up to 10 days 1
For Confirmed GAS, the American Academy of Pediatrics recommends penicillin or amoxicillin as first-line treatment, with a treatment duration of 10 days to prevent rheumatic fever 3