Pharyngitis Alice Lee Resident Conference September 22, 200

1
Pharyngitis

• Alice Lee
• Resident Conference
• September 22, 2005

2
Patient History

• HPI 16 yo M presents with 1 week h/o sore throat
  accompanied by right neck swelling. He notes
  progressive fatigue, fevers to 100.3, some N/V
  with abdominal pain, headache without
  photophobia, pain with urination. On admission
  day, he noticed difficulty opening his R eye.
• No sick contacts, recent travel, congestion,
  cough/resp symptoms, SOB, rash, diplopia

3
Patient History

• PMH Viral meningitis 3 yrs ago, Vaccinations
  UTD
• PSH Circumcision 5 yrs ago
• Soc hx Homosexual, 1st and only episode of
  unprotected sex 1 wk PTA after onset of symptoms.
  Neg tob/EtOH/drugs
• Fam hx GF DM, HTN
• Meds None
• NKDA

4
Patient Exam

• T36.6, HR70, BP105/50, RR 12, 100RA
• Gen Alert but fatigued, responsive no stertor,
  stridor, drooling ptotic R eyelid but PERRL,
  EOMI, no chemosis, gross VA intact B
• Ears AD inflamed TM with bulging ME pus, AS
  WNL, ACgtBC AU, Weber to R
• Nose - clear
• OC/OP - Enlarged, erythematous R tonsil with
  exudate trismus, R mandibular 2nd molar TTP

5
Patient Exam (continued)

• Neck Swollen R neck with TTP, palp mult nodes
  in level II
• CN II-XII intact bilat and symmetric except for
  R ptotis. V1-V3, all branches VII intact
  bilaterally

6
Labs

• Admission labs
• CBC 22.3/14/39/10, 95 N
• Coags PT 15.2, INR 1.1
• Chem 131/3.2/90/26/24/1.1/137
• LFTs Elevated total bili 6.2, direct bili 4.1,
  AST, ALT, total protein WNL
• U/A - neg

7
Studies

• CXR
• CT
• MRI

8
Differential Diagnosis - Pharyngitis

• V
• I FB, smoking, medications (prednisone,
  inhalers), PND/AR/sinusitis, thyroiditis, globus
  pharyngeus, Crohns disease
• T laryngeal trauma
• A Behcets disease, benign mucous membrane
  pemphigoid
• M LPR, goiter
• I Sarcoidosis, glossopharyngeal neuralgia,
  neuralgia of internal branch of superior
  laryngeal
• N Lymphoma, SCC, thyroid neoplasm
• C Eagles syndrome/styalgia

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Differential Diagnosis - Pharyngitis
10
Pharyngitis lab work-up

• GABHS rapid antigen detection test
• This is the preferred method for diagnosing GABHS
  infection in the ED because of difficulties with
  culture follow-up.
• A throat swab should follow a negative result.
• Rapid antigen detection is not sensitive for
  Group C and G streptococci or other bacterial
  pathogens.
• Throat culture
• This is the criterion standard for diagnosis of
  GABHS infection (90-99 sensitive).
• Positive cultures are clinically important only
  in patients with a related clinical illness less
  than 10 days old.
• Antistreptolysin-O (ASO) is a highly sensitive
  test but it is not practical in the ED because of
  the need for acute and convalescent titers.

11
Pharyngitis lab work-up

• Mono spot is up to 95 sensitive in children
  (less than 60 sensitivity in infants).
• Peripheral smear may show atypical lymphocytes in
  infectious mononucleosis.
• Perform gonococcal culture, as indicated by
  history.
• Routine labs usually are not available for A
  hemolyticus, M pneumoniae, or C pneumoniae.
• Fluorescent monoclonal antibody test exists for C
  pneumoniae.
• A complete blood count (CBC), erythrocyte
  sedimentation rate (ESR), and C-reactive protein
  have a low predictive value and usually are not
  indicated.

12
Pharyngitis imaging studies

• Imaging studies generally are not indicated for
  uncomplicated viral or streptococcal pharyngitis.
• Lateral neck film should be taken in patients
  with suspected epiglottitis or airway compromise.
• A chest x-ray can elucidate pneumonia in M
  pneumoniae or C pneumoniae infection or in other
  clinically suspected lower respiratory infection.

13
Lemierres syndrome

• Characterized by 4 classic findings
• Primary oropharynx infection (but reported
  parotitis, sinusitis, mastoiditis, otitis, dental
  infection as sources)
• Documented blood culture positive septicemia
• Clinical or radiographic evidence of IJV
  thrombosis
• At least one metastatic focus of infection

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Epidemiology

• Andre Lemierre, 20 cases, 1936
• Only several hundred reported cases
• Four-fifths of reported cases are in patients 18
  or older youngest age 5 yrs. Another series, 70
  patients between ages 16-25
• About 30 pediatric cases reported (since 1980)
• MF
• 0.6 to 2.3 cases per million people per year
  (Hagelskjaer, et al)
• Mortality decreased from 90 to approximately
  4-18 in post-antibiotic era (Brazier)

15
Microbiology

• Usually Fusobacterium necrophorum, occasionally
  Bacteroides, anaerobic Streptococcus,
  Lactobacillus, other Fusobacterium species
  reported, polymicrobial
• F. necrophorum produces proteolytic enzymes
  which disrupt the mucosal barrier of oropharynx ?
  platelet aggregation/intravascular coagulation
  ?tissue destruction and hypoxia ? O2 free
  environment for proliferation of anaerobic
  bacteria

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Pathogenesis

• Lateral pharyngeal space as source of initial
  infection
• Direct extension, hematogenous, or lymphatic
  spread to IJV
• Septic emboli can spread from IJV to other
  organs. 90 of cases present with distant septic
  emboli at time of diagnosis. Most common sites
  lung gt joints
• Virchows triad RFs for thrombosis

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Clinical manifestations

• Pharyngitis or tonsillitis days to weeks
• Lateral neck pain, swelling, persistent fever
• Pulmonary decompensation/dyspnea/pleuritic chest
  pain/hemoptysis
• Myalgias/ arthralgias
• Others abdominal pain, hepatomegaly, diffuse
  encephalopathy, jaundice

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Lab findings

• Moderate leukocytosis 15K-20K, left shift
• Elevated ESR
• Mild transaminase elevation, anemia, elevated
  amylase, sterile pyuria
• Blood culture positive, usu F. necrophorum

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Imaging

• CXR Infiltrates, embolic, pleural effusions,
  empyema, normal
• Studies demonstrating IJV thrombophlebitis U/S,
  CT with contrast, MRI

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Treatment

• Antibiotics anaerobic coverage (clinda, flagyl,
  PCN with B lactamase inhibitor, cephalosporin
  with B lactamase inhibitor and anaerobic
  coverage, combos), 7-14d IV, then 2-4wks po
• F. necrophorum generally not susceptible to
  aminoglycosides
• Anticoagulation for septic emboli
• Surgery for drainage of abscesses
• Rare need for IJV ligation unless persistent
  septic emboli despite adewuate medical rx

21
References

• Bailey
• Cummings
• Brazier JS. Fusobacterium necrophorum intections
  in man. Rev. Med. Microbio. 200213(4)141-9
• Dool H, et al. Lemierres syndrome three cases
  and a review. Eur Arch Otorhinolaryngol. 2005
  Aug262(8)651-4.
• Hagelskjaer LH, et al. Incidence and clinical
  epidemiology of necrobacillosis. Eur J Clin
  Microbiol Infec Dis 199817561-5.
• Lucente F. 1999. Essentials of Otolaryngology.
  Philadelphia Lippincott Williams and Wilkins.
  217-224.
• Masterson T, et al. A case of the otogenic
  variant of Lemierre's syndrome with atypical
  sequelae and a review of pediatric
  literature.Int J Pediatr Otorhinolaryngol. 2005
  Jan69(1)117-22
• Ochoa R, et al. Clinicopathological conference
  Lemierres syndrome. Acad Emerg Med. 2005
  Feb12(2)152-7.
• Venglarcik J. Lemierres syndrome. Pediatr Infect
  Dis J. 2003 Oct22(10)921-3.