Pharyngitis

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Pharyngitis

• Melanie Vadnais D.O.
• Stephanie Carlin D.O.

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Definition

• Pharyngitissore throat
• Localized erythema of the pharynx, soft palate,
  tonsils, tonsillar pillars and sometimes the
  adenoids with or without exudates
• Most commonly secondary to viral or bacterial
  infection

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Epidemiology

• Uncommon in children less than 1 yr
• Incidence increases to a peak at 4-7 yr but
  continues throughout later childhood and adult
  life
• In younger children it is most commonly due to a
  virus and may be a component of a generalized URI

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O.K., so whats the big deal?
STREPTOCOCCUS PYOGENES- GROUP A BETA-HEMOLYTIC!!!!
GABHS
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Etiology- Viral

• Adenovirus
• EBV
• Influenza A, B
• Parainfluenza
• Enteroviruses
• Measles

• CMV
• HSV
• Rhinovirus
• RSV
• HIV

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Etiology- Bacterial

• Strep pyogenes- GABHS
• Grp C or G Strep
• Arcanobacterium hemolyticum
• C. Diphtheriae and hemolyticum
• N. gonorrhea and meningitidis
• M. pneumoniae and hominis

• C. pneumoniae and psittaci
• Yersinia enterocolitica
• Francisella tularensis
• Treponema pallidum
• Oral anaerobes

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Etiology- Fungi

• Candida Species- oral thrush
• Usually seen in infants and immunosuppressed
  individuals

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Chronic Pharyngitis- usually noninfectious

• Irritation from postnasal discharge of chronic
  allergic rhinitis
• Chemical irritation
• Neoplasms
• Vasculitides

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Exudative Pharyngitis D/D

• Streptococcus pyogenes
• Streptococcus Grp C and G
• Adenovirus
• EBV
• N. gonorrhea
• C. diphtheria and hemolyticum
• Francisella tularensis

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Back toGABHS!!!!!

• Most common in children 5-15 yr
• No sex or race predilection
• In the U.S., 10 of children are evaluated by
  medical care providers each year for pharyngitis
  and 25-50 of them have GABHS
• However, 20 of asymptomatic children are long
  term carriers of GABHS
• Rates higher in enclosed populations-daycare
• Transmissible to close contacts via droplet

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GABHS

• Encapsulated gram positive bacterium
• M protein antiphagocytic
• Lipoteichoic acid colonization
• Extracellular products
• Streptolysin O
• Deoxyribonuclease B
• Hyaluronidase
• Erythrogenic/Pyrogenic toxins

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So how do we diagnose it?

• Sx viral vs bacterial not easily distinguishable
• H P (S/S)
• High index of suspicion!!!!
• Rapid Strep Test
• Throat cx
• /- Monospot/EBV serology

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History- 1962 Feinstein et al

• The only typical feature of streptococcal
  infections is their failure to show a single,
  consistent, typical feature.

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Viral Pharyngitis S/S

• Sore Throat
• Fever (gradual onset)
• Hoarseness
• Rhinorrhea
• Cough
• Pharyngeal erythema

• /- tonsillar exudate
• Anterior cervical LAD
• Malaise
• Anorexia
• Pharyngeal ulcer

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GABHS Pharyngitis S/S

• Sore Throat
• Fever
• HA
• Abdominal Pain
• Pharyngeal erythema
• ? Tonsillar exudate
• Tonsillar hypertrophy

• 5-15 yr
• Palatial petechiae
• Anterior cervical LAD
• Dysphagia
• Vomiting
• Malaise
• Scarlatiniform rash
• Winter/Spring

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Strep Clinical Scoring Systems

• Devised to predict the probability of GABHS
  infection
• PPV70-80
• Features most strongly suggestive of strep
  pharyngitis
• 5-15 yr
• Clinical evidence of
• Acute pharyngitis
• Fever
• Absence of URI S/S

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GABHS- lt 2 yr old

• Uncommon
• May produce a more persistent illness
  streptococcosis
• Characterized by coryza w/ postnasal discharge,
  variable fever (lasting 4-8wks), pharyngitis,
  anorexia, and tender cervical lymphadenitis

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GABHS- gt 2 yr old

• Begins with nonspecific complaints of HA,
  abdominal pain, and vomiting
• High fever (104 degree F) x 1-4 days
• Shortly after initial presentation the sore
  throat may become severe
• Only 1/3rd of patients demonstrate classic
  tonsillar enlargement, exudates, and pharyngeal
  erythema
• Anterior cervical LAD- tender

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Rapid Strep Antigen Detection Tests (RADTs)

• LPA, ELISA, GABHS antigens
• Sensitivity 62-95
• Specificity 88-100
• Disadvantages
• Cost
• Confirmation
• Overreading

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Throat Culture

• Sensitivity 90-97
• Specificity 95-100

Gold Standard for GABHS
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To treat or not to treat?.That is the million
dollar question.

• WellSo what is the most important goal of
  treatment?

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Acute PharyngitisComplications

• Suppurative
• Retropharyngeal abscess
• Peritonsillar abscess
• Acute cervical adenitis
• Acute sinusitis
• Acute OM
• cellulitis

• Non-Suppurative
• Acute Rheumatic Fever
• Acute Post-Streptococcal Glomerulonephritis
• TSS
• PANDAS

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Acute Post-Strep Glomerulonephritis (APSGN)

• Sequelae of pharyngitis/skin infection
• Caused by nephritogenic strains of GABHS
• S/S 10 days post-strep pharyngitis
• S/S 3 wks post-strep dermatitis
• Antibiotics NO PREVENTATIVE EFFECT!!!!!
• Hematuria- tea/cola-colored urine
• oliguria HTN urinary rbc casts

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Acute Rheumatic Fever (ARF)

• Sequelae of GABHS pharyngitis
• rheumatogenic strain of GABHS
• S/S 18 days post-infection
• Antibiotics- PREVENTATIVE!!!!!
• Remember those Jones Criteria? Urgh!?!

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Modified Jones Criteria

• Modified Jones Criteria two majors or one major
  two minors required
• Major criteria carditis, migrating
  polyarthritis, chorea, erythema marginatum,
  subcutaneous nodules.
• Minor criteria fever, arthralgia, elevated acute
  phase reactant (CRP or ESR), prolonged PR
  interval (i.e., first degree AV block)
• Plus All must have evidence of streptococcal
  infection (positive ASO titer, Streptozyme,
  positive streptococcal throat culture)

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Pediatric Autoimmune Neuropsychiatric
disorders(PANDAS)

• Association with strep infection
• Manifests as a sudden onset or episodic course of
  obsessive-compulsive and/or tic disorders

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O.K..thats right back to Treatment!

• Since even exudative tonsillitis is usually of
  viral origin, for which there is no specific
  therapy, the use of antibiotics should be guided
  by the results of RADTs or cultures, unless there
  are strong clinical and epidemiologic grounds to
  suspect a streptococcal infection.

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Treatment

• D.O.CPenicillin V orally
• 250 mg lt 27 kg (60 lb)
• 500 mg for older children and adults
• BID-TID x 10 days
• Non-compliant pts single IM injection of
  Benzathine Penicillin G
• 600,000 U lt60 lbs
• 1,200,000 U gt60 lbs

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Streptococcal Pharyngeal Carrier

• Repeated, frequent episodes of pharyngitis with
  () GABHS labs
• Problematic
• Carrier vs intercurrent viral
• Clinical findings
• Epidemiologic factors in the community
• Clinical response to antimicrobial therapy
• () GABHS labs between episodes
• ASO response

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Pharyngeal Carriers

• Antimicrobial therapy is not indicated for most
  carriers
• Exceptions
• Outbreak of ARF/PSGN
• Outbreak in a closed/semi-closed community
• Family h/o ARF exists
• Multiple episodes of documented symptomatic GABHS
  pharyngitis continue to occur within a family
  during a period of many weeks despite appropriate
  therapy
• Family with excessive anxiety about GABHS
  infections
• Tonsillectomy is considered only because of
  chronic GABHS carriage

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Quiz Case 1

• 7 yr. girl presents to your office with the
  sudden onset of fever, HA, and N/V. On exam
  Temp 102 HR 110 She is ill appearing but
  non-toxic. She has a erythematous, fine,
  sandpaper-like rash all over her body.
  Circum-oral pallor. Her O-P is beefy red and her
  tongue has a strawberrry appearance. She has
  tender cervical adenopathy. Whats your dx?

Answer GABHS/Scarlet Fever
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Case 1
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Quiz Case 2

• 5 yr boy presents with c/o ST x 2 days. VS Temp
  101. On exam he has a runny nose- clear, his
  conjunctiva are injected b/l, and you appreciate
  3-4 pinpoint erythematous papules/vesicles in his
  posterior O-P. You also notice that he has a dry
  cough and has a hoarse voice. Whats your dx?

Answer more likely to be viral
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Case 2 (continued)

• Which virus in particular is associated with
  acute pharyngitis and acute conjunctivitis?
• Hinthint also known as pharyngoconjunctical
  syndrome.

Answer Adenovirus
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Quiz Case 3

• 4 yr. girl presents to your office 2 days after
  you dx her with GABHS (RADT ()) and started her
  on Amoxicillin now with the appearance of a rash-
  papular eruption on her face and trunk. Her PE
  findings included pharyngeal erythema and
  tonsillar enlargement. You also appreciated
  tonsillar exudates and tender cervical
  adenopathy. Whats going on here?

Answer EBV
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Case 3
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Question 3 continued

• So now your thinking EBV. What are you going to
  do to confirm your dx?

Answer EBV serology
Pitfall reliance on Monospot test in young
children (lt 5yr)
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True/False

• Swabbing the throat from anywhere in the mouth is
  adequate.
• You can feel comfortable dx GABHS solely on the
  basis of your clinical exam findings.
• Redbook guidelines state to treat all pts with
  () GABHS test regardless of S/S.

FALSE
FALSE
FALSE
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True/False

• Treating GABHS pharyngitis does not prevent PSGN.

TRUE!!!!!!
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Thanks for your attention!!!
Have A Great Day!