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CCE2: Medicine Block > Acute upper respiratory symptoms > Flashcards

Acute upper respiratory symptoms Flashcards

1
Q

What are the differential diagnoses for acute upper Resp symptoms/ sore throat?

A
  • Acute sore throat
  • Acute pharyngitis (Most common cause of sore throat)
  • acute tonsillitis
  • common cold
  • acute rhino- sinusistis
  • acute cough
  • acute bronchitis
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2
Q

Relevant anatomy to URTI/ sore throat:

What are the 4 paranasal sinuses?

What are they lined by and where do they drain?

Role of paranasal sinuses?

A
  • Frontal, ethmoid, sphenoidal and maxillary
  • Paranasal sinuses - lined by respiratory epithelium and all drain into the nasal cavity
  • role is to warm & humidify air, and reduce the weight of the skull.
  • Drainage:
    • ​Sphenoid sinus –> drains into the roof of the nasal cavity via sphenoethmoidal recess, pituitary gland can be accessed through nasal roof into sphenoid sinus and throught sphenoid bone
    • Frontal sinus –> drains via frontonasal duct into middle meatus (at hiatus semilunaris)
    • Ethmoidal sinus –> ethmoid air cells separated from orbit by thin layer of bone - lamina papyracea (infection can spread into orbit causing periorbital cellulitis). Drains via hiatus semilunaris in middle meatus.
    • Maxillary sinus –> drains against gravity, again via hiatus semilunaris at middle meatus. Close relationship to maxillary teeth - inflammation of this sinus can present with toothache.
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3
Q

Differentail : Acute pharyngitis/ acute sore throat

Pathophysiology?

Common causitive organisms?

A

Acute pharyngitis - infection & inflammation of the pharynx most commonly due to viral organisms or group A streptococcus.

Common viral causes:

  • Epstein barr virus (mononucleosis) (do not miss) - often mild inflammation of mesenteric lymph nodes therefore abdo pain
  • adenoviruses - high fever and non exudative pharyngo-conjunctival inflammation
  • enteroviruses
  • influenza A &B
  • parainfluenza

Group A streptococcus - spread from person-person via resp droplets (only 1/3 cases). Can also be caused by other streptococci - B/C/G.

STI - HIV/chlamydia/ gonorrhoea may be implicated in sexually active adolescents

Candida - immunocompromised individuals

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4
Q

RF’s for acute pharyngitis?

Demographics?

A

Risk factors:

  • Nasal colonisation w group A Streptococcus
  • contact with a person with group A streptococcus
  • sexual activity/ abuse
  • ingestion of non domestic meats
  • immunocompromisation/ inhaled steroids - candida pharyngitis
  • lack of vaccination - diptheria or measles

Commonly affected:

  • Age 5-15 yrs - Group A streptococcus common
  • Winter or spring - Group A streptococcus common
  • Summer or autumn - Enteroviral pharyngitis more common
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5
Q

Acute pharyngitis:

Key features on the history?

A
  • Age - 5-15 yrs - acute GAS pharyngitis common in this age group
  • GAS pharyngitis more common in winter or early spring
  • Enteroviral more common in summer and autumn
  • Symptoms:
    • Sore throat
    • pharyngeal exudate - common with GAS, other streptococci, EBV
    • painful anterior cervical adenopathy (predict streptococcal)
    • fever (temp > 37)
    • headache
    • N&V + abdominal pain common in children
    • rhinorrhoea & nasal congestion + cough - typically present in viral pharyngitis ABSENT in bacterial pharyngitis
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6
Q

Acute pharyngitis:

Key features on examination?

A

Key signs of group A streptococcal pharyngitis:

  • Pharyngeal exudate
  • oedemtaous
  • erythematous
  • cervical adenopathy (painful anterior cervical adenopathy is common in GAS)
  • Fever
  • lack of cough or rhinorrhoea

Viral infection - presence of rhinorrhoea, nasal congestion and cough

Gonococcal infection also be anterior cervical lymphadenopathy

Rashes - scarlatinform rash can present in children, suggestive of GAS

Koplik spots - bluish-white raised lesion on red base on buccal mucosa (like grains of white sand surrounded by red ring) - measles. Plus maculopapular rash.

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7
Q

Acute pharyngitis:

Investigations?

A
  1. Rapid antigen detection tests for Group A Streptococcal infection / throat swab and culture
    • Used in under 5’s only, not recommended above clinical criteria for older patients
    • negative GAS rapid antigen test in children should be followed by throat swab and culture as increased risk rheumatic fever
  2. Monospot test - rapid identification test for EPV (infectious mononucleosis)
  3. Adults w pharyngitis:
    • Use Centor criteria
      • screen for hx of fever/ lack of cough/ tonsillar exudates/ tender anterior cervical adenopathy
      • adults with none/ only 1 of these criteria should not be tested or treated for GAS
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8
Q

Management of acute pharyngitis?

A
  • Analgesia / local anaesthetics/ salt water gargle for sx
  • Avoid aspirin in children - associated with Reye’s syndrome
  • Abx –> only for microbiologically confirmed (w +ve rapid antigen test or culture for group A streptocci)
  • Group A streptococcus pharyngitis:
    • Prevent acute rheumatic fever
    • reduce severity and transmission
    • Treatment of choice = penoxymethylpenicillin -10 days
    • if penicillin allergy –> macrolide/ cephalosporin or clindamycin
  • Retropharyngeal abscess –> surgical drainage, ABX,
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9
Q

Causes URTI/sore throat:

Tonsillitis

Define

A
  • Acute tonsillitis = acute infection of parenchyma of the palatine tonsils
  • tonsilitis may occur in isolation or as part of generalised pharyngitis
  • clinical distinction between acute tonsillitis and pharyngitis = unclear, often referred to as “acute sore throat”

Pathophysiology:

Local inflammation results in oropharyngeal swelling, oedema, erythema and pain, swelling can progress to soft palate and uvular (uvulitis) or inferiorly to region of supraglottis ( this is rarer).

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10
Q

Relevant anatomy to tonsillitis:

Waldeyer’s ring is formed of that tissue collections?

A
  • Tonsils = collections of lymphatic tissue located within the pharynx - collectively form ring arrangement called Waldeyer’s ring.
  • Formed of:
    • Pharyngeal tonsil
    • Tubal tonsils x 2
    • Palatine tonsils x 2
    • Lingual tonsil
  • Tonsils = MALT - mucosa associated lymphoid tissue- contain T cells/ B cells/ macrophages - first line of defence in pathogens entering nasopharynx or oropharynx.
  • Lingual tonsil - numerous lymphoid nodules within submucose of posterior third of the tongue, inferior part of waldeyer’s ring
  • Pharyngeal tonsil - collection of lymphoid tissue within mucosa of roof of nasopharynx - when enlarged known as the adenoids - forms superior aspect of waldeyer’s ring. Covered in ciliated pseudstratified epithelium,
  • Tubal tonsils –> lymphoid tissue surrounding opening of eustachian tube in lateral wall of nasopharynx - forms lateral aspect of waldeyers ring - ciliated pseudostratified epithelium
  • Palatine –> often referred to as “tonsils” - located within tonsillar bed lateral oropharynx wall between palatoglossal arch and palatopharyngeal arch - form lateral part of waldeyers ring.
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11
Q

Causative organisms for tonsillitis?

A
  • Usually viral:
    • Rhinovirus
    • coronavirus
    • adenovirus
    • Less common:
      • parainfluenza
      • enterovirus
      • herpes virus
      • EBV - infectious mononucleosis
  • Bacterial:
    • beta haemolyti and other streptococci - most common Group A beta-haemolytic streptococci - more common in children
    • Group C beta haemolytic streptococci less commn
    • Mycoplasma pneumoniae
    • neisseria gonorrhoea - sexually active adolescents
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12
Q

How can we differentiate between viral and bacterial aetiolology in Tonsillitis?

A

The Centor criteria: predicts likelihood of patient > 14 yrs having GABHS infection

  • History of fever over 38
  • tonsillar exudate
  • absence of cough
  • tender anterior cervical lymphadenopathy

If 3/4 of centor criteria are met - PPI of Group A beta haemolytic streptocci infection

If abscence of 3 met - highly unlikely group A beta haemolytic streptococci infection

Or FeverPAIN criteria: 1 point for each, higher score more likely streptococcal cause

  • Fever - past 24 hrs
  • Purulence - pus on tonsils
  • attend rapidly - w/in 3 days onset of sx
  • severely inflamed tonsils
  • no cough or coryza
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13
Q

Key signs/ symptoms in hx of tonsillitis?

A
  • pain on swallowing
  • fever > 38
  • tonsillar exudate/ erythema/enlargement
  • Sudden onset sore throat
  • headache
  • abdo pain
  • N&V
  • presence of cough or runny nose –> suggest viral URTI
  • enlarged painful anteriot cervical lymph nodes =–> common in group A beta haemolytic streptococcal tonsilitis
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14
Q

RF for tonsillitis?

Demographics?

A
  • RF’s –> age between 5- 15 yrs (More likely to be streptococcal infection)
  • contact w infected individuals in enclosed spaces - e.g. childcare centre/school/ prison
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15
Q

Examination in tonsillitis?

Investigations?

A
  • Examination:
    • tonsilar erythema/ enlargement/ purlent exudate
    • enlarged anterior cervical lymph nodes
    • fever > 38
  • Investigation:
    • usually based off clinical presentation
    • if severe = rapid streptococcal Ag test +/- throat swab culture
    • only in children > 3 yrs and adults w high probability of Strep infection
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16
Q

Management of tonsillitis?

A
  • Analgesia –> paracetamol/NSAID/ local A spray/lozenges (Lidocaine)/ salt gargle
  • Abx –> only in Group A beta haemolytic streptococci infections / indicated in critically unwell or from vulnerable population where rheumatic fever is high ( south adrica/ australian indiginous/maori/ developing country)
  • Penicillin 10 day course 1st line
  • Macrolide = erythromycin/ azithrpmycin/ clarithromycin
  • cephalosporin or clindamycin
  • Tonsillectomy –> patients w recurrent tonsillitis
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17
Q

What are the complications of bacterial tonsillitis?

A
  • Peritonsilar abscess = quinsy
    • sx - dysphagia, worsened sore throat
    • unilateral bulge with deviation of the uvula
    • Robot voice - dont want to intonate properly
    • degree of lock jaw
    • IV abx - steroids - LA and needle aspiration or incision and drainage
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18
Q

Causes of acute URTI/ sore throat:

Common cold - define

A

Common cold = acute self limiting inflammation of mucus membranes of the upper resp tract - may involve all of nose/ throat/ sinuses/ pharynx

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19
Q

Common cold RF/ demographics?

A
  • RF’s:
    • exposure to affected individuals
    • young age
    • winter season
    • day care attendance
    • exposure to cigarette smoke
20
Q

Common cold –> common organisms?

Pathophysiology?

A
  • 50% caused by rhinoviruses
  • 15% coronavirus
  • 15% influenza
  • 5% parainfluenza
  • 5% RSV - resp sycytial virus
  • adenoviruses (pharyngitis) / enteroviruses

Pathophysiology: influx of polymorphonuclear leukocytes in nasal submucuosa within a few days of viral infection causes sx

21
Q

Key features in the history for common cold?

A
  • Onset 1/2 days
  • fever
  • rhinorrhoea - clear or purulent
  • sneezing
  • sore throat
  • hoarseness
  • decreased taste/ smell
  • pressure in ears/ sinus
  • coughing - day 4/5 due to PN drip
22
Q

Common cold:

exam

investigations

management

A
  • exam:
    • may have pharyngeal exudate
    • check centor criteria to exclude bacterial cause
  • Investigation:
    • unnecessary - diagnosis supported by negative culture
  • Management:
    • symptomatic –> steam/ vapour rubs/ salt gargle/ lozenges
    • Fluids, rest, avoid aspirin in children
    • avoid abx –> self limiting
23
Q

Causes of acute UR symptoms / sore throat:

Acute (rhino)sinusitis - define

A
  • Acute rhinosinusitis = symptomatic inflammation of mucosal lining of the nasal cavity and paranasal sinuses, clinical sx present for 4 weeks or less. Caused by either viral or bacterial infection.
24
Q

Acute (rhino)sinusitis:

causative organisms?

Pathophysiology?

A

Causative organisms:

  • Viral most common: rhinovirus, influenza, parainfluenza, adenovirus
  • viral sinusitis often resolves within 10 days
  • Bacterial less common: in small number of cases viral sinusitis will progress to bacterial (0.5-2%)
    • streptococcus pneumoniae
    • haemophilus influenzae
    • moraxellla catarrhalis
  • Bacterial sinusitis often more severe, takes > 10 days to resolve
25
Q

Acute (rhino)sinusitis:

Pathophysiology?

A
  • Inflammatory changes to the sinuosal mucosa due to viral infection –> inflammation causing mucosal oedema, neutrophil recruitment, increase mucus production.–> polyps develop which trap mucus in
  • Leads to blocking of sinus drainage & increased pressure in sinus –> further inflammation
  • bacteria can take advantage of static mucociliary clearance –> leads to bacterial growth, epithelial cell death, further inflammatory cell infiltration, leading to pus formation
  • Added bacterial infection with strep pneumonia/ haemophilus influenza/ moraxella catarrhalis
26
Q

Key features of Acute (rhino)sinusitis in history?

(symptoms)

A
  • Symptom severity distingushes between bacterial vs viral
    • Sx present less than 10 days - viral
    • sx present > 10 days - bacterial
    • sx that get better then worse - secondary bacterial infection
  • Bacterial sx:
    • facial pain/ pressure
    • headache
    • nasal obstruction w purulent nasal discharge
    • dental pain
  • Viral:
    • fever
    • sore throat
    • myalgia
    • clear nasal discharge
  • Cough common sx in both viral and bacterial - PND or asthma exacerbation
27
Q

Examination features for Acute (rhino)sinusitis?

A
  • Head & neck examination:
    • facial tenderness on palpation
    • post nasal pharyngeal secretions or exudate
    • tender maxillary dentition
    • middle ear effusion
  • Nasal cavity:
    • mucosal erythema or purulent discharge
    • unilateral purulent secretion/ oedema erythema + facial tenderness – > think bacterial
  • Nasal Endoscopy: in patients not improving
    • visualise nasal cavity and sinus drainage pw/s
  • RF’s –> periorbital or malar oedema, orbital proptosis, visual disturbance, abnormal extra ocular movements or neurological sings – complications likely
28
Q

Investigations for Acute (rhino)sinusitis?

A

EPOS guideline criteria: Acute sinusitis can be diagnosed with symptoms and either endscopic or CT findings

Key sx: congestion/ rhinorrhoea/ facial pain or pressure/ reduced or total loss of smell (anosmia or cacosmia)

Nasal endocscopy --> may show mucosal erythema and purulent discharge if diagnosis is unsure - pt not responding to abx. May also see polyps or obstruction of the middle meatus (where frontal maxillary and ant/ lat ethmoid sinuses drain)

Sinus culture –> to tailor abx if resistance suspected

CT sinuses: if complications are suspected

29
Q

Rf’s for Acute (rhino)sinusitis?

A

Allergic rhinitis (leads to inflammation of mucosa, can block sinus ostium (opening of sinus drainage) or recent upper resp tract infection - proceeds to bacterial sinusitis

30
Q

Management of Acute (rhino)sinusitis?

A

Viral:

  • rest, warm facial packs, steam inhalation
  • analgesia/ antipyretic: paracetaol, ibuprofen, codeine
  • Decongestant: oxymetazoline, pesudoephedrine
  • intranasal corticosteroid
  • intranasal saline:
  • mucolytic

Bacterial:

  • Abx: co-amoxiclav OR clindamycin AND a cephalosporin OR doycycline OR fluroquinolone
  • Treatment as above (viral)

severe or recurrent –> ENT referral

31
Q

Acute rhinositis:

What are the complications that can develop?

A
  • Frontal mucocele
  • subperiosteal abscess - pots puff tumour = abcess under periosteum
  • intracerebral infection
  • orbital abscess
  • cavernous sinus thrombosis
32
Q

Causes of acute upper resp symptoms/ sore throat

Acute bronchitis - define

key features?

A
  • Acute bronchitis = self limiting low RTI. Refers specifically to infections causing inflammation in the bronchial airways (e.g NOT in actual lung tissue, pneumonia denotes infection in lung parenchyma)
  • Acute illness < 21 days
  • cough predominant symptoms
  • 1 other lower RT symptoms –> sputum production/ wheezing / chest pain
33
Q

Causitive organisms of acute bronchitis?

Pathophysiology?

A
  • Most cases of acute bronchitis are viral infections –> coronavirus, rhinovirus, RSV, adenovirus
  • Can be caused by bacteria - chlamydia pneumoniae and mycoplasma pneumoniae

Pathophysiology:

  • acute inflammation of bronchial wall due to infection
  • increased mucus production and oedema of bronchus
  • leads to productive cough - hallmark of LRTI
  • infection may clear in days, repair of bronchial wall may take several weeks
  • During repair, patients continue to cough (half of patients continue to cough > 2 weeks).
34
Q

Key features on hx for acute bronchitis?

A
  • Acute Cough - productive
  • symptoms suggestive of bronchial obstruction –> intermittent wheeze or SOB
  • Other signs of resp infection:
    • rhinorrhoea
    • sore throat
    • low grade fever
  • illness last less than 3 weeks, cough can last for uo to two weeks (50%) and up to 4 weeks (25%)
  • look for more severe sx of pneumonia –> pain/fever/malaise/ rigours/ haemoptysis
  • RF’s –> cough > 30 days, haemoptysis, weight loss
  • PMH: Clarify chronic resp conditions –> e.g. asthma
  • Medication: ACE i (Can induce cough)
  • SH: smoking
  • Occupational Hx: any exposure to dusts / chemicals
35
Q

Key examination features for chronic bronchitis?

A
  • Nasal congestion
  • Coryza (inflammation of mucuous membrane in nose)
  • pharyngeal hyperameia (excess blood in vessels) - looks oedematous/ erythematous
  • Wheeze - prolonged expiratory
  • Rhonchi - low pitched contiunuous rattling lung sounds (like snoring) due to obstruction or secretions in larger airways
  • rales - pneumonia or CHF
36
Q

Investigations for acute bronchitis?

A
  • Clinical diagnosis based off hx and exam
  • persistent cough, fever, abscence of other symptoms suggestive of alternative diagnosis
  • Consider:
    • CXR –> pneumonia
    • CRP –> if abx considereing
    • viral identification –> rapid test for influenza can be used if available
37
Q

Management of acute bronchitis?

A

No significant wheeze with cough: observation and symptomatic - ibuprofen paracetamol

significant wheeze and cough : SABA salbutamol and antitussive

cough > 4 weeks - evaluate for other causes, salbutamol, consider ABX

38
Q

LO: consider probability of glandular fever and peritonsillar abscess (quinsy)

Define glandular fever

A
  • Glandular fever = infectious mononucleosis - clinical syndrome commonly caused by Epstein barr virus (EBV) in 80-90% of cases
  • Infectious mononucleosis —> used when syndrome caused by EBV
  • “mononucleosis syndrome” –> used when non EBV agent
  • Typically manifest in adolescents/ young adults as febrile illness w sore throat and enlarged lymph nodes
39
Q

LO: consider probability of glandular fever and peritonsillar abscess (quinsy)

What is the pathophysiology of glandular fever (infectious mononucelosis)?

A
  • 80-90% of IM cases caused by EBV (also known as human herpes 4)
  • Remaining EBV negative cases - Human herpes virus 6, cytomegalovirus, herpes simplex virus 1
  • Most commonly transmitted through saliva hence - “kissing disease”.
  • EBV primarily infects the oropharyngeal B cells via the tonisllar crypts
  • Circulating infected B cells then spread the infection to liver/spleen/peripheral lymph nodes
  • Initiates humoral and cellular immune responses to the virus - rapid T cell response crucial for suppression
  • Antibodies produced directed against EBV structural proteins = viral capsid, early antigens, EBC nuclear antigen.
  • Primary infection (lytic stage) then followed by the latent stage - EBV immortalises in infected lymphocytes
  • low level of ongoing viral replication and infection of B cells in tonsillar and lymphoid tissues, controlled by EBV specfic T cells.
40
Q

LO: consider probability of glandular fever and peritonsillar abscess (quinsy) :

Key signs/ symptoms of glandular fever?

A
  • Diagnosis confirmed by classic triad of: Fever, pharyngitis and lymphadenopathy (plus atypical lymphocytosis (abnormal morphology of the WBC’s), a positive agglutination test for heterophile antibodies and positive serological test for EBV specific AB’s)
  • Commonly 10-30 yrs old
  • fatigue/ malaise= very common
  • Rash - (10% adults, 1/3rd paediatric patients) - appears first few days of illness up to a week. Rash can appear due to viral infection itself, can be due to Abx - amoxicillin/ penicillin.
    • erythematous
    • maculopapular
    • morbilliform
  • Uncommon signs:
    • myalgia
    • jaundice
    • spleno and hepatomegaly
  • Often gradual development of illness, in some patients it may be abrupt onset.
  • Sx of IM may resolve within days or persist up to 4 weeks (up to 8 in some)
  • For complete resolution of fatigue, it may take several months
  • Can present abnormally w guillian barre, facial nerve palsy or encephalitis in children in abscence of typical IM signs.
41
Q

LO: consider probability of glandular fever and peritonsillar abscess (quinsy)

Examination signs in Glandular fever?

A

Common:

  • Lymphadenopathy - cervical or generalised
  • Pharyngitis/ tonsillitis (exudative or non exudative)
  • Malaise
  • Fever
  • Spelenomegaly
  • Enlarged tonsils

Uncommon:

  • Myalgia
  • Hepatomegaly
  • Rash - maculopapular, erythematous, morbilliform
  • Jaundice
42
Q

LO: consider probability of glandular fever and peritonsillar abscess (quinsy)

What are the investigations for glandular fever?

A

Bloods:

  • FBC -->
    • Lymphocytosis with greater than 50% (seen in 70% of cases), highest in second and third week
    • Atypical lymphocytosis greater than 10% seen in 90% cases - not specific for EBV
    • anaemia and reticulocytosis (increase in reticulocytes (immature RBC’s), identifies haemolytic anaemia secondary to EBV infection
  • Heterophile antibodies
    • Non specific for EBV
    • IgM AB’s agglutinate RBC from other species - monospot test = rapid qualitative slide agglutination test
    • false negative in first week = 1/4 , less in 2nd and 3rd week
  • EBV specific AB’s:
    • Test has high sensitivty and specificity
    • Viral capsid antigen IgM - detectable w symptoms onset, peaks 2-3 weeks, immeasurbale at 4 months
    • Viral capsid IgG peaks 2-3 months and persists for life
    • Antibodies to early antigens rise in acute phase - undetectable by 3-4 months
    • Nucelar antigen - rises in resolution and remains detectable for life - can identify past infection
  • LFT’s:
    • Transaminase elevated
  • Consider: PCR - to detect EBV, USS abdo - splenomegaly confirm, CT abdo - if suspecting splenic rupture
43
Q

LO: consider probability of glandular fever and peritonsillar abscess (quinsy)

What is the treatment/ management of glandular fever/ infectious mononucleosis?

A

Supportive - paracetamol and ibuprofen, good hydration, antipyretics and analgesia. (x Aspirin in children - Reyes syndrome).

Avoid contact sports for up to 8 weeks due to risk of splenic rupture, avoid alcohol

If airway obstruction or haemolytic anaemia and Thrombocytopenia –>

admit+ prednisilone + IV Ig (immunoglobulin)

44
Q

Peritonsilar abscess

how does it present?

A

Rare complication of bacterial tonsillitis —> peritonsillitus –> abscess

patients present with severe sore throat - worse unilaterally associated with severe painful swallowing (odynophagia).

Plus stertor (noise from vibration of pharyngeal tissues - oropharynx, soft palate- due to significant upper resp obstruction ) and Trismus (lockjaw)

Other symptoms: fever, drooling, halitosis, ipsilateral earache, stiff neck, headache

45
Q

Peritonsilar abscess:

Examination features?

A
  • Extensive erythema (may have some exudate)
  • soft palate swelling ipsilateral, anterior arch pushed medially, anterior displacement of ipsilateral tonsil and deviated uvula
  • tender ipsilateral cervical lymphadenopathy
  • Asymmetrical twisted neck - torticollis - patient keeps neck tilted on affected side
46
Q

What is the management of a peritonsillar abscess/ quinsy?

A
  • Patients need to be admitted
  • start on IV abx
    • penicillin/ cephalosporin/amoxicillin/
  • regular analgesia/ throat sprays
  • require LA needle aspiration or incision and drainage
    • culture aspiration to tailer ABX choice
  • In severe cases/ recurrent cases tonsillectomy may be indicated

CCE2: Medicine Block (20 decks)

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