Pharyngitis

Question 1

What causes Pharyngitis?

Answer 1

60-90% of cases are viral-related

bacteria account for 5-30% of cases

Question 2

When and in what group is Pharyngitis most common?

Answer 2

winter

in children ages 4-7

Question 3

What type of infection can result from Bacterial Pharyngitis?

Answer 3

14% of deep neck infection is caused by bacterial pharyngitis

Question 4

What are tonsils?

Answer 4

small masses of lymphoid tissue around the pharynx that trap and remove bacteria and other foreign materials
adenoid, tubal, palatine, and lingual tonsils

Question 5

What causes tonsillitis?

Answer 5

congestion with bactera

Question 6

What are common causes of Pharyngitis?

Answer 6

Streptococci
viral infection (Herpes/Coxsackievirus, CMV, EBV)
oral candidiasis
STIs - more common in younger groups
other bacteria (non-group A streptococcus, fusobacterium, mycoplasma pneumoniae, Chlam. pneumoniae, adn A. haemolyticum, Diphteria)
differentiated by throat culture

Question 7

What is important to know about patients that have Mononucleosis and secondary streptococcal tonsilitis?

Answer 7

1/3 of patients have secondary tonsilitis
ampicillin/amoxicillin should be avoided because it induces a rash in mononucleosis patients that could be misinterpreted as a penicillin allergy

Question 8

How long does Pharyngitis last?

Answer 8

incubation lasts 1-3 days, but may last as long as 7 days
patients are contagious until 24 hours after they have begun antibiotics or for as long as symptoms persist if not treated

Question 9

How is Pharyngitis treated?

Answer 9

antibiotics - penicillin
can decrease symptom duration and severity if given within 48 hours
no known penicillin resistance in the U.S.

Question 10

What is GABHS and why is it important?

Answer 10

Group A Beta Hemolytic Strep; a type of bacteria that releases a toxin that could cause Scarlet Fever

Question 11

Why do we worry about Strep Throat?

Answer 11

if not treated within 9 days, it could develop into
Rheumatic FEver
Glomerulonephritis with Acute Renal Failure
Peritonsillar Abscess
Pneumonia, otitis, sinusitis, osteromyelitis, mastoiditis, menigitis, or septic arthritis

Question 12

What is Rheumatic Fever?

Answer 12

cardiac inflammation and scarring triggered by an autoimmune reaction to infection with group A streptococci

Question 13

How is Rheumatic Fever prevented?

Answer 13

can be prevented if treated with antibiotics in the first 9 days of symptom onset

Question 14

What are common symptoms of Strep Throat?

Answer 14

sore throat
dysphagia
fever
malaise
headache
rash
exudative tonsils
palatal petechiae (tiny red spots that occur in response to infection; reaction of lymph system)
tender anterior cervical lymphadecnopathy
abdominal pain
vomiting (especially in kids)

Question 15

What is Scarlet Fever?

Answer 15

develops as a result of strep throat
red rash, strawberry tongue (early on can look like thrush), and desquamation (occurs after 1 week of infection; peeling of the palms and feet)

Question 16

What are the center criteria for treating Strep Throat?

Answer 16

fever or history of fever
exudate or tonsillar hypertrophy
tender laterocervical adenopathies
lack of cough
age: under 15 = 1 point, over 45 (-1 point)
4 (37-57%)
3 (25-35%)
2 (10-17%)
1 (10%)
none (2%)

Question 17

Rapid Strep Test vs. Culture

Answer 17

PPV 90-99%
subject to quality of sample (eating and drinking effects results)
culture is 90% sensitive and 99% specific
culture may give you other causes for sore throat like Mycoplasma, Chlamydia, Candidia, and Gonococcus
culture may help establish carrier state

Question 18

How is Strep Throat treated?

Answer 18

penicillin first!
Adults: Pen-V, bicillin LA (Pen-G), Azithromycin, Cefprozil
Children: Amoxacillin or PenV, bicillin LA (Pen G), Azithromycin, Cefprozil

Question 19

What are complications that can occur if Pharyngitis is not treated?

Answer 19

inflammatory diseases that are not direct infections but where the immune response to streptococcal antigens causes injury to host tissues (Rheumatic Fever, GLomerulonephritis with Acute Renal Failure)
Extension to deeper tissue (deep neck infection, osteomyelitis, mastoiditis)
bacterial seeding/spread (pneumoniae, otitis, sinusitis, meningitis, septic arthritis)

Question 20

What is Perianal Strep?

Answer 20

Strep can present as rectal pain and constipation in children 3-5 years old
establish strep by culturing throat and rectum; treat as chronic carrier
consider recurrent tonsilitis, family outbreaks

Question 21

What is Rheumatic Fever (in more detail)?

Answer 21

prolonged febrile inflammation of connective tissues; body-wide, but particularly in the heart and joints

Question 22

What are characteristics of Rheumatic Fever?

Answer 22

fever, carditis, subcutaneous nodules and migratory polyarthritis

cardiac enlargement, valvular murmurs, and effusions are seen clinically

Question 23

When does Rheumatic Fever begin and how long does it last?

Answer 23

begins 3 weeks (1-5 weeks) after GABHS pharyngitis

Lasts 2-3 months

Question 24

At what age does the first Rhumatic Fever attack usually arise?

Answer 24

ages 5-15 (carried for a lifetime)
repeated attacks lead to progressive damage to the endocardium and heart valves, with scarring and valvular stenosis or incompetence which can lead to heart failure

Question 25

How do you treat a chronic Strep carrier?

Answer 25

IM Bicillin LA - long-acting injectable penicillin (treatment of choice)
augmetnin is the preferred oral method (in longer lasting, more serious cases or for patients with a penicillin resistance)
Clindamycin or Cephalosporins for penicillin allergic (NOT AZITHROMYCIN)
change all toothbrushes and glassware

Question 26

How are Deep Tissue/Neck Infections related to pharyngitis?

Answer 26

GABHS have the capacity to be highly invasive and can extend from the pharynx and oral cavity to the deep neck

Question 27

Why are Deep Tissue/Neck Infections crucial to prevent?

Answer 27

It can be life threatening.
Once the infection reaches the neck, it can spread to the mediastinum, carotid sheath, skull base, and meninges. Mortality rates are 20-50%.
If there are issues beyond the tonsils or extension into the soft spaces, refer emergently!!

Question 28

What is Glomerulonephritis?

Answer 28

inflammation of the glomeri that occurs in reaction to the presence of GABHS toxin

Question 29

What symptoms occur as a result of Glomerulonephritis?

Answer 29

hypertension
hematuria (blood in the urine - first sign)
proteinuria
edema due to inflammation of the renal glomerulus

Question 30

How is Glomerulonephritis treated?

Answer 30

Not treated immediately; the course is usually benign and will heal itself in weeks to months. Follow closely to make sure that a progressive course does not lead to renal failure or death.

Question 31

Peritonsiallar Abscess

Answer 31

asymmetric (big clue) deviation of tonsils
voice changes
difficulty swallowing saliva
neck pain
five days of throat pain - think abscess
hot potato voice
treated with antibiotics
ENT referral is needed
may need to be drained

Question 32

How are GABHS carriers identified?

Answer 32

RST and/or culture is positive when asymptomatic
ASO titer (heterogenous in acute infection; homogenous in carrier state)
not if one family member is always unaffected (have culture and titer drawn)

Question 33

Tonsillar Hypertrophy

Answer 33

noninfection pharyngeal issue
chronic enlargement of tonsils and adenoids lead to snoring/apnea
tonsillectomy for recurrent infection (3 in 3 yrs, 5 in 2 years, 7 in one year)

Question 34

Soft Palate Resection

Answer 34

most common surgical correction to relieve snoring

Question 35

Viral Pharyngitis

Answer 35

itchy throat, on and off symptoms, little ulcers, very compact presentation

Question 36

Bacterial Pharyngitis

Answer 36

wake up with horrible symptoms