pharyngoconjunctival fever (adenovirus) These viral infections are closely followed in frequency by bacterial infections caused by group A streptococci (Streptococcus pyogenes ) During streptococcal outbreaks, as many as 30% to 50% of episodes of pharyngitis may be caused by S pyogenes in school-aged children Another common infectious agent in pharyngitis is the Epstein–Barr virus, which causes infectious mononucleosis Although infectious mononucleosis is not often seen in children younger than years ( Fig 74.1 ), it commonly affects the adolescent One additional important consideration in adolescents with an infectious mononucleosis-like syndrome is acute human immunodeficiency virus (HIV) infection, which does not commonly cause significant pharyngeal inflammation Other organisms produce pharyngitis only rarely; these include Neisseria gonorrhoeae, Corynebacterium diphtheriae, Francisella tularensis, Fusobacterium necrophorum, and other bacteria N gonorrhoeae may cause inflammation and exudate but more often remains quiescent, being diagnosed only by culture Diphtheria is a life-threatening but seldom encountered cause of infectious pharyngitis, characterized by a thick membrane and marked cervical adenopathy Oropharyngeal tularemia is rare and should be entertained only in endemic areas among children who have an exudative pharyngitis that cannot be categorized by standard diagnostic testing and/or persists despite antibiotic therapy Although unusual, mixed anaerobic infections should be considered in the ill-appearing adolescent with a severe pharyngitis because these organisms occasionally lead to complications such as infected thrombophlebitis and sepsis (Lemierre syndrome) Arcanobacterium haemolyticum has been isolated from 0.5% to 2.0% of adolescents with pharyngitis, often in association with a maculopapular rash Other pathogens—group C and G streptococci, Mycoplasma pneumoniae, and Chlamydia pneumoniae —have been implicated as agents of pharyngitis in adults, but in childhood, their roles remain unproven and their frequency is unknown Irritative Pharyngitis/Foreign Body Drying of the pharynx may irritate the mucosa, leading to a complaint of sore throat This condition occurs most commonly during the winter months, particularly after sleeping in a house with forced hot-air heating Occasionally, a foreign object such as a fishbone or popcorn shell may become embedded in the pharynx resulting in pain Herpetic Stomatitis