GAS/Pharyngitis/Tonsilitis

Question 1

Epidemiology:

• When is pharyngitis/tonsilitis more common
• At which age is it more common

Answer 1

• season: GAS pharyngitis more common in late winter or early spring; viral all year long
• age: GAS pharyngitis peak incidence at 5-12 yr of age and uncommon <3 yr; viral pharyngitis affects all ages

Question 2

Symptoms of tonsilitis

Answer 2

• viral:
  • sore throat (often mild), conjunctivitis, cough, rhinorrhea, hoarseness, diarrhea, flu-like symptoms (fever, malaise, myalgias)
• GAS:
  • sore throat (may be severe), absence of cough, high fever, malaise, headache, abdominal pain, N/V, absence of other URTI symptoms

Question 3

Scarlet fever:

• What is it
• Natural history
• DDx

Answer 3

• = delayed-type hypersensitivity reaction to pyrogenic exotoxin produced by GAS
• Rash fades after 3-4 days
- Dengue - can look sunburnt

Question 4

Compare signs in viral vs bacterial pharyngitis.

Answer 4

• GAS:
  Febrile, pharyngeal/tonsillar erythema, tonsillar exudates (giving ‘strawberry and cream’ appearance’, enlarged (>1 cm) and tender anterior cervical lymph nodes, palatal petechiae, strawberry tongue, scarlatiniform rash (most discriminatory feature)
• viral:
  afebrile, absent/mild tonsillar exudates, minor and non-tender adenopathy, viral exanthems

Question 5

What Mx options are there for tonsilitis?

Answer 5

• Supportive: hydration, analgesia, anti-pyretic
• Abx
  • Routine use is no longer indicated(only e.g. ATSI, requires hospitalisation)
  • Phenoxymethylpenicillin for 10 days/cephalexin
• Corticosteroids can be added to antibiotic therapy if symptoms are very severe (eg restricted swallowing, drooling)
• F/U not needed if uncomplicated
• prophylaxis: consider tonsillectomy for proven, recurrent streptococcal tonsillitis

Question 6

What are some non-suppurative complications of GAS (esp in children)?

Answer 6

• acute rheumatic fever
• post-strep GN
• reactive arthritis
• PANDAS

Question 7

How does quinsy present?

Answer 7

trismus, severe unilateral throat pain, high fever and/or a change in voice

Question 8

What is the spectrum of disease that GAS can cause?

Answer 8

• Pharyngitis
• Impetigo, erysipelas, cellulitis
• Bacteraemia
• Pneumonia
• Necrotising fasciitis
• Myositis
• Osteomyelitis, septic arthritis
• Perianal cellulitis
• Endocarditis
• Streptococcal toxic shock syndrome

Question 9

Clinical features of scarlet fever

Answer 9

• Fever, sore throat, strawberry tongue
• Scarlatiniform/sandpaper rash 24-48h after:
  
  • diffuse blanching erythema with papular elevations
  • Pastia’s lines - arked in skin folds and pressure pointse.g. groin, axillae, cubital fossa
  • Palms, soles, perioral area spared
  • non-pruritic/tender

Question 10

Which is more common cause of pharyngitis/tonsilitis: virus/bacteria (and which)

Answer 10

• viral (~80%):
  • adenoviruses, enteroviruses, coxsackie, upper respiratory tract viruses, EBV, CMV
• bacterial (~20%):
  • 15-30% of all cases are GAS pharyngitis (peak of incidence 3-15yo)
  • M. pneumoniae (older children)

Question 11

What are some red flags for airway obstruction with complicated pharyngitis/tonsilitis?

Answer 11

• Voice changes
• Drooling
• Stridor
• Torticollis
• Trismus
• Swelling below the mandible

Question 12

What are the conditions that can cause airway obstruction with pharyngitis/tonsilitis?

Answer 12

• Peritonsilllar abscess (Quinsy)
• Infectious mononucleosis (EBV)
• Epiglottitis/Bacterial Tracheitis
  (more likely if unimmunised againstH. influenzae)
• Retropharyngeal abscess/Lateral pharyngeal abscess