URTI Pharangitis

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URTIPharangitis

• Mohammed El-Khateeb
• MSVL-4
• Nov 26th 2013

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OVERVIEW
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URTI WHY IS THIS IMPORTANT?

• The respiratory system is the most commonly
  infected system.
• Health care providers will see more respiratory
  infections than any other type.

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Geography of the respiratory system (and sites of
infection)
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THE RESPIRATORY SYSTEM

• A major portal of entry for infectious organisms
• The upper respiratory tract
• Mouth, nose, epiglottis, Nasal cavity, sinuses,
  pharynx, and larynx
• Infections are fairly common.
• Usually nothing more than an irritation
• The lower respiratory tract
• Lungs and bronchi
• Infections are more dangerous.
• Can be very difficult to treat

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ANATOMY OF THE RESPIRATORY SYSTEM

• The most accessible system in the body,
  continuously exposed to potential pathogens.
• Breathing brings in clouds of potentially
  infectious pathogens.
• The body has a variety of host defense
  mechanisms.
• Innate immune response The cells and mechanisms
  that defend the host from infection by other
  organisms, in a non-specific manner
• Adaptive immune It is adaptive immunity because
  the body's immune system prepares itself for
  future challenges.

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• Protective structures of the
• respiratory system
• Ventilatory flow
• Involuntary responses such as coughing,
• sneezing and swallowing
• Mucous membranes
• Hairs ciliated epithelia
• Lymphoid tissues (tonsils)
• Mucociliary escalator keeps microbes
• out of lower respiratory tract
• Alveolar macrophages IgA

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The Respiratory Tract and Its Defenses

• Normal Flora
• Moraxella,
• nonhemolytic and a-strep,
• Coryenbacterium,
• Diphtheroids,
• Candida albicans,
• Others

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Pharnygitis
Sore Throate

• Definition
• Inflammation of the mucous membranes and
  submucosal structures of the oropharynx but not
  tonsils

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ETIOLOGY

• 30-65 idiopathic
• 30-60 viral
• 5-10 bacterial
• Group A beta-hemolytic most common bacterial
  pathogen
• 15-36 pediatric cases
• 5-10 adult pharyngitis
• Disease of children

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Etiology

• Strep.A
• Mycoplasma
• Strep.G
• Strep.C
• Corynebacterium diphteriae
• Toxoplasmosis
• Gonorrhea
• Tularemia

• Rhinovirus
• Coronavirus
• Adenovirus
• CMV
• EBV
• HSV
• Enterovirus
• HIV

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Pharyngitis

• Pharyngeal mucosa exhibits an inflammatory
  response to many other agents other than viruses
• Opportunistic bacteria
• Fungi
• Environmental pollutants
• Neoplasm
• Granulomatous disease
• Chemical and physical irritants

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Incidence

• Sore throat is estimated to account for 10 of
  all general practice consultations
• Asymptomatic carriage of streptococcus
• Is common with rates of 6 - 40
• Carriers have low infectivity and are not at risk
  of developing complications such as rheumatic
  fever

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Pharyngitis

• Inflammation of the throat
• Pain and swelling, reddened mucosa, swollen
  tonsils, sometime white packets of inflammatory
  products
• Mucous membranes may swell, affecting speech and
  swallowing
• Often results in foul-smelling breath
• Incubation period 2-5 days

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Clinical manifestation (Viral)

• Sore throat
• Pain on swallowing
• Fever
• Hoarseness if laryngeal involvement

• Gradual onset
• Rhinorrhea
• Cough
• Diarrhea
• Headache
• Malaise

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Signs

• Redness of the pharynx and tonsils
• Presence of exudate
• Enlarged tonsils
• Swollen tender neck glands.
• Note that a streptococcal sore throat is
  impossible to diagnose on clinical grounds alone.

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Physical Examination

• Full head and neck exam
• General respiratory distress, toxic
• Face mouth breathing
• Nose rhinorrhea
• Neck lymph nodes, thyroid,
• Mucosal edema, tonsillar swelling, exudates,
  discrete lesions, deviation of the uvula or
  tonsillar pillars, bulges in the posterior
  pharyngeal wall
• Laryngoscopy
• Nasal endoscopy - sinusitis

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PHARYNGITIS

• Treatment
• VIRAL Supportive care only Analgesics,
  Antipyretics, Fluids
• No strong evidence supporting use of oral or
  intramuscular corticosteroids for pain relief ?
  few studies show transient relief within first
  1224 hrs after administration
• EBV infectious mononucleosis
• activity restrictions mortality in these pts
  most commonly associated with abdominal trauma
  and splenic rupture

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Complications
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Sinusitis

• Commonly called a sinus infection
• Most commonly caused by allergy
• Can also be caused by infections or structural
  problems
• Generally follows a bout with the common cold
• Symptoms nasal congestion, pressure above the
  nose or in the forehead, feeling of headache or
  toothache
• Facial swelling and tenderness common
• Discharge appears opaque with a green or yellow
  color in case of bacterial infection
• Discharge caused by allergy is clear and may be
  accompanied by itchy, watery eyes

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Acute Otitis Media (Ear Infection)

• Also a common sequel of rhinitis
• Viral infections of the upper respiratory tract
  lead to inflammation of the Eustachian tubes and
  buildup of fluid in the middle ear- can lead to
  bacterial multiplication in the fluids
• Bacteria can migrate along the eustachian tube
  from the upper respiratory tract, multiply
  rapidly, leads to pu production and continued
  fluid secretion (effusion)
• Chronic otitis media when fluid remains in the
  middle ear for indefinite periods of time (may be
  caused by biofilm bacteria)
• Symptoms sensation of fullness or pain in the
  ear, loss of hearing
• Untreated or severe infections can lead to
  eardrum rupture

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Figure 21.2
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Infectious causes of pharyngitis
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Viruses

• Most common agents in pharyngitis are the
  rhinovirus and coronavirus
• Both single stranded, sense RNA picornaviruses
• Grow best at 33 degrees Celsius
• Approximates the temperature of the nasopharynx
• Disease is self-limited
• Clinical signs and symptoms may be identical to
  bacterial pharyngitis
• Evaluation for Group A streptococcus is advisable

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Viruses

• Major cause of acute respiratory disease
• Rhinovirus Coronaviruses
• Respiratory syncicial virus
• Parainfluenza viruses
• Respiratory syncicial virus
• Herpes Group
• HIV

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VIRAL INFECTIONS OF THE UPPER RESPIRATORY TRACT
(URT)

• RHINOVIRUS INFECTION -There are several hundred
  serotypes of rhinovirus.
• Fewer than half have been characterized.
• 50 that have are all picornaviruses.
• Extremely small, non-enveloped, single-stranded
  RNA viruses
• Optimum temperature for picornavirus growth is
  33C.
• The temperature in the nasopharynx

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VIRAL INFECTIONS OF THE UPPER RESPIRATORY TRACT

• PARAINFLUENZA There are four types of
  parainfluenza virus.
• All belong to the paramyxovirus group.
• Single-stranded enveloped RNA viruses
• Contain hemagglutinin and neuraminidase
• Transmission and pathology similar to influenza
  virus, but there are differences.
• Parainfluenza virus replicates in the cytoplasm.
• Influenza virus replicates in the nucleus.

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..PARAINFLUENZA

• Parainfluenza is genetically more stable than
  influenza.
• Very little mutation
• Little antigenic drift
• No antigenic shift
• Parainfluenza is a serious problem in infants and
  small children.
• Only a transitory immunity to reinfection
• Infection becomes milder as the child ages.

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Respiratory Syncytial Virus Infection

• Produces giant multinucleated cells (synctia) in
  the respiratory tract
• Most prevalent cause of respiratory infection in
  the newborn age group
• First symptoms fever that lasts approximately 3
  days, rhinitis, pharyngitis, and otitis
• More serious infections give rise to symptoms of
  croup coughing, wheezing, dyspnea, rales

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Epstein-Barr Virus (EBV)

• Etiologic agent of infectious mononucleosis (IM)
• Herpes virus 4
• Double stranded DNA virus
• Selectively infects B-lymphocytes

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Ebstein-Barr Virus (EBV)

• Early infections in life are mostly asymptomatic
• Clinical disease is seen in those with delayed
  exposure (young adults)
• Defined by clinical triad
• Fever, lymphadenopathy, and pharyngitis combined
  with heterophil antibodies and atypical
  lymphocytes

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Ebstein-Barr Virus (EBV)

• Other clinical findings
• Splenomegaly 50
• Hepatomegaly 10
• Rash 5

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Ebstein-Barr Virus (EBV)

• Pharyngitis
• White membrane covering one or both tonsils
• Petechial rash involving oral and palatal mucosa

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Ebstein-Barr Virus (EBV)

• Diagnosis
• By Clinical presentation
• CBC with differential (atypical lymphocytes T
  lymphocytes)
• Detection of heterophil antibodies (Monospot
  test)
• IgM titers

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Treatment

• Supportive management
• Rest
• Avoidance of contact sports (?-gtsplenic rupture?)
• Glucocorticoids (severe cases)

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Ebstein-Barr Virus (EBV)

• Complications
• Autoimmune hemolytic anemia
• Cranial nerve palsies
• Encephalitis
• Hepatitis
• Pericarditis
• Airway obstruction

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Cytomegalovirus (CMV)

• Herpes virus 5
• Ubiquitous
• 50 of adults seropositive
• 10-15 of children seropositive by age 5 years
• Etiology of 2/3 of heterophil-negative
  mononucleosis

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Cytomegalovirus (CMV)

• Clinical manifestation
• Fever and malaise
• Pharyngitis and lymphadenopathy less common
• Esophagitis in HIV infected patients

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Cytomegalovirus (CMV)

• Diagnosis
• 4-fold rise in antibody titers to CMV

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Herpes Simplex Virus (HSV)

• Herpes (Greek word herpein, to creep)
• Two antigenic types (HSV-1, HSV-2)
• Both infect the upper aerodigestive tract
• Transmission is by direct contact with mucous or
  saliva

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Herpes Simplex Virus (HSV)

• Clinical manifestations
• Depends on
• Anatomic site
• Age
• Immune status of the host
• First episode (primary infection)
• More systemic signs and symptoms
• Both mucosal and extramucosal sites involved
• Longer duration of symptoms

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Herpes Simplex Virus (HSV)

• Clinical manifestations
• Gingivostomatitis and pharyngitis most common
  in first episode
• Usually in children and young adults
• Fever, malaise, myalgias, anorexia, irritability

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Herpes Simplex Virus (HSV)

• Physical exam
• Cervical lymphadenopathy
• Pharynx exudative ulcerative lesions
• Grouped or single vesicles on an erythematous
  base
• Buccal mucosa
• Hard and soft palate

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Herpes Simplex Virus (HSV)

• Clinical manifestations
• Acute illness evolves over 7-10 days
• Rapid regression of symptoms
• Resolution of lesions

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Herpes Simplex Virus (HSV)

• Immunocompromised patient
• Persistent ulcerative lesions are common in
  patients with AIDS
• Lesions more friable and painful
• Aggressive treatment with IV acyclovir

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Herpes Simplex Virus (HSV)

• Diagnosis
• Usually clinical
• Isolation of HSV
• Culture from scrapings of lesions
• Results in 48 hours

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Herpes Simplex Virus (HSV)

• Treatment
• Acyclovir, 400 mg PO 5X/day X 10days
• Valacyclovir, 1000 mg PO BID X 10 days
• Recurrent disease
• Acyclovir 400 mg PO 5X/day for 5 days
• Duration reduced from 12.5 to 8.1 days
• Acyclovir 400 mg po bid every day
• Recurrence reduced 36 to 19

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Human Immunodeficiency Virus (HIV)

• Pharyngitis
• Usually opportunistic infection
• HSV
• CMV
• Candida
• Viral particles have been detected in
  lymphoepithelial tissues of the pharynx