Sore Throat Flashcards
Best LRS for diagnosing strep
Tonsillar exudates
pharyngeal exudates
exposure to strep in last 2 weeks
other good ones : scarletiform rash palatine petichiae pharyngeal exudate vomitting and tender cervical adenopathy associated with GABHS pharyngitis
Best negative LRS for diagnosing strep
absence of enlarged tonsils
absence of tender cervical adenopathy
absence of exudate
decrease the chance of strep
What is GABHS pharyngitis?
Group A Beta hemolytic strepococal pharyngitis
strep throat
FeverPAIN scale
fever, purulence, attend rapidly, inflammed tonsils, no cough or coryza
used for streptococcus
WHO strep approch
treat all children with pharyngeal exudate and enlarged tender cervical lymph nodes
not recommended
specific but not sensitive
High moderate and low risk patients with potential strep throat Tx
Empiric - Abx for high risk
symptomatic therapy and follow up for low risk
delayed prescription and rapid antigen testing for moderate risk
T or False
the absence of exudate is enough to effectively rule out streptococcal pharyngitis as the bacteria congregate on the tonsils. Thus, the lack of exudate indicated no bacteral infection.
False :
no individual element of history taking or physical exams are accurate enough alone to rule in or out strep
However : Creamy exudate from tonsillar pillars b/c pf pustular nature of the infection
Why do we care about knowing if it’s strep or not?
complications from strep may arise such as scarlet and rheumatic fever
Which lymph nodes drain the pharynx?
relevance
Anterior cervical nodes – which may become tender and enlarged during infection. (strep)
Is GABHS a commensal bacteria?
No, not apart of the normal throat flora
DDxs of strep
pharyngitis tonsilitis viral infections absecesses epiglotitis Epstein Bar Virus
Strep presentation in adults vs children
Strep in adults is rapid onset
Symptoms less focal and more gradual in children
Both:
Severe throat pain and difficulty swallowing
Fever 39-40.5
Also typically present with malaise, mild stiff neck, GI symptoms
PE for strep?
what will we see? (5)
Examination of throat – erythema, edema of pharynx and uvula
Diffuse erythema and hypertrophy of the lymphoid tissue
Post pharynx pillars covered with grey white exudate, and it is beefy bright red, colour ending abrumptly at soft palate
Petichae on soft palate
Tonsils swollen with exudate
Breath is characteristically foul
Which condition is a complication of GABHS?
how does it present? 4
Scarlet Fever
erythematous papules trunk spreading sparing the palsm and soles
Blanches,
strawberry tongue
Pharyngeal ulcers also suggest group a b hemplytic strep
At what age does Step peak?
5-10 years
Centor’s 4 item clinical prediction rule
explain
tonsillar exudate, swollen tender anterior cervical nodes, absence of cough, and history of fever. 1 point assigned for each of the patients signs and symptoms
Subtract ones if older than 45
used for the diagnosis of strep
Score 3-4 increases strep prob
0-1 very low risk
Most common and freuqnet sore throat cause
other common (5)
viral infection of the pharynx (pharyngitis)
common cold influenza mononucleiosis environmental exposure strep
Which structures are vital in emergency throat issues?
epliglottis : if inflammed can close off airway - emergent
Common Strep thoriat ‘no’ signs
No nasal symptoms
no cough
maybe some anterior cervical lymph node swelling
Localized vs. diffuse thorat pain
localized : more suggestive of a bacteria
diffuse - more viral
How long do bengin sore throats take to heal?
within 5 days to resolve
Worse on waking sore thorat
post nasal drip, mouth breathing, sleep apnea
worse after meals sore throat
GERD maybe
Red flags for sore throat (5)
due to? (3)
Airway distress (stridor, tachypnea, tripod posture, drooling, cyanosis)
due to obstruction (abscess, edema, neoplasm)
Pain on swallowing ST
pharynx (vs. larynx)
Fever and ST
Fever
infectious cause
Nasal symptoms and ST
allergies, viral
Cough and ST
viral, reflux, post nasal drip
Lymphadenopathy and ST
mono(systemic)
, bacterial infection, neoplasm?
Voice change and ST
abscess or enlarged tonsils; laryngeal involvement
Globus (what is it?)
and ST
foreign body sensation; throat clearing)
neoplasm, GERD, post nasal drip
Pharyngitis/Tonsilitis
info
presentation
ddx?
Most commonly associated with viral upper respiratory tract infection
Commonly associated with low fever, cough, runny nose, lethargy
Rule out : Group A β-hemolytic Strep (and other bacterial causes)
15-30% of pediatric cases
More likely to have fever, more pain, anterior cervical adenopathy; lacking nasal symptoms or cough
White exudate on tonsils that are enlarged
DDX
Tonsiltis
Strep
tonsils can be enlarged in kids because the immune system is working
Red petichiae on palate and uvula
ddx
strep
mono
increases suspicison of bacterial infection
Why do we care about strep with a ST? (6)
Other 2
Only cause of pharyngitis for which antibiotics may be indicated
Risk of otitis media, peritonsillar abscess, rate of rheumatic fever, glomerulonephritis
BUT substantial decline of the incidence of complications in high-resource settings
Most cases of pharyngitis will self-resolve
Testing for Strep
Throat culture gold standard, high sensitivity BUT higher cost and delayed treatment
Rapid strep test : quick (10-20 min), and high specificity (can rule in) BUT low sensitivity (can’t rule it out, especially in children)
limitations of testing for strep
Neither Rapid strep test or throat culture can distinguish between carriage (5-20% of children) and actual infection
(some kids just habour the bacteia without active infection - this is a problem - leads to chronic infections etc. )
What is the most appropriate thing to do if there is a suspected absess?
why?
Peritonsilar - clinical assessment
ultrasound or CT (might not be able to see on PE)
Retro/parapharyngeal abscess
- MRI
CT(might not be able to see on PE)
CBC (septicemia might be suspected)
predictors / increased likelihood of strep ( 5)
score /implcations
Age 3-14 Tonsillar swelling or exudate No cough Temperature > 38°C anterior cervical adenopathy
1 point for each : low score - no culture of Abx
high score - 4 : RST - throat culture and Abx
medium more : RST, if negative proceed to culture because it’s not sensitive enough to rule out
Main concerns with pharyngitis
Sx
peritonsillar/retropharyngeal abscess, epiglottitis
Worsening or persistence of symptoms (should peak at day 3)
Drooling, difficulty swallowing, respiratory distress, tripod positioning, stridor
Trismus, muffled voice (“hot potato voice”)
Stiff neck, external/unilateral neck swelling (neuro signs - meningitis)
High fever, shaking chills, night sweats
Supraglottitis/Epiglottitis
what?
cause?
presentation?
medical emergency
infection of epiglottis and larynx with H. influenza B or β-hemolytic Strep
Severe sore throat, odynophagia, high fevers
Varying degrees of airway involvement
Muffled voice, stridor, tachypnea, drooling, tripod position, use of accessory muscles
sudden swelling –> obstruction
What to do if you suspect Epiglottitis
Don’t do a PE
Call 911
if a child is in respiratory distress, call 911 and try to keep the child calm and comforatble
What might be done for a child with suspected e\piglottitis in the ER?
Intubate
X ray - see a thumb sign
Laryngoscope is most sensitive
CT if suspect an associated abscess (secure the airway)
what is the thumb sign?
“thumb sign” Epiglottitis. Widened epiglottis and aryepiglottic folds
Epstein-Barr Virus
class
causes?
transmission
Herpes virus
Cause of mononucleosis : Lymphoproliferative disorder
Transmission via oral ingestion of viral particles (kissing, sharing drinks, etc.)
Populations that get mono the most
young adults 10-48 in NA
Pathogenesus of EBV
ingested inhaled etc. infects B cells
Rupture of B-cells and transmission of virus to new cells
T ceel proliferates (CD8Ts, NKs) to destroy infect B cells
B cell produce Abs
IgM (acute), IgG (previous), Heterophil Abs
Why is there widespread lymphadonopathy in mono?
because T cells proliferate, infection of B cells therefore , the infection happens systemmically
Splenomegaly and relevance?
enlarged spleen
relevant in acute EBV
Enlarged liver and releavnce
hepitis which may develop in EBV
What happens once EBV has been cleared by the body?
there are a small population of infectedB cells that may activate or proliferate
rare
IgG serology
Possible Mononucleosis presentation (12
Fever
pharyngitis
extreme fatigue
swollen tonsils
exudate
petichiae
body rash ( non specific)
generalized lymphadenopathy
Splenomegaly
Hepatitis, pneumonitis, meningoencephalitis
Body rash with ST after amoxicicillin/penicillian use
treated on suspicion of GABHS
treated for the wrong organism
they have mono therefore non-specific body rash
How long does it take for mono to clear?
Can last 3 weeks
fatigue can last for months
What to do if you suspect mono?
rapid strep test to rule out strep
culture
Clinical features of Mono
sore throat, lymph node enlargement, fever and tonsillar enlargement
- 98% (very typical lof mono)
pharyngeal inflammation
- 85%
petichiae (50%)
Posterior cervical lymphadenopathy
higher LR in Mono (3,1)
Confirmatiory labs for EBV/Mono
(4) and why?
- CBC and peripheral blood smear
Lymphocytosis (increases WBC)
Distinctive atypical lymphocytes (CD8) - Monospot (heterophil antibody)
(doesn’t rule it out) - Rapid strep test … why?
- Serology
IgM and IgG for EBV (viral capsid antigen, nuclear antigen)
Also titers (Abs) for Cytomegalovirus (looks like EBV)
What is a monospot test?
what does it test for?
Heterophil Antibodies
blood mixed with sheep, and reacts and clumps if positive
(doesn’t rule it out)
What do IgM Abs suggest?
relevant condition?
Acute infection
discussed in mono ( EBV)
Possible complications with EBV
Hepatic involement ( hepatistis)
splenic rupture ( more sensitive)
Possible long term sequele of EBV (4)
Nasopharyngeal carcinoma
Burkitt lymphoma
Chronic Fatigue Syndrome? Fibromyalgia?
more likely to be malignant if incapable of controlling B cell activity
Rhinosinusitis/post-nasal drip:
and ST presentation
Irritated throat, globus, excessive phlegm, cough
Other manifestations of rhinorrhea, congestion, facial pressure, etc.
what is globus?
foriegn body sensation in the throat
Neoplasm and ST
Globus, irritation
well localized pain
voice change
weight loss
lymphadenopathy
Thyroiditis and ST
Hyperthyroid symptoms
(heat intolerance, restlessness, agitation, diarrhea, tremor, etc.)
Visibly enlarged thyroid gland
Hoarseness
involves what?
how long?
red flags?
Involving the larynx (not typically painful)
More concerning when persistent (ie. >3 weeks)
voice overuse, steroid use, recurrent URTI etc.
Red flags:
smoking, dysphagia, odynophagia or otalgia, stridor, haemoptysis and recent fevers, night sweats and unexplained weight loss
more concerned about persistant : want to rule out malignancy
Laryngitis
what?
why?
predisposition?
infancy?
typically d/t URTI, or smoking
tobacco related presiposition for cancer
serious in infancy due to croup , exudate, edema etc
Vocal cord polyps/nodes
what?
who?
other 2
common begnin tumor
nodes : bilat , polyps : unilat
rarely develops into cancer
due to irritation : heavy smokers and singers
constant trauma : attempt to repair : other side might ulcerate with contact
Papilloma ST
what?
what might happen?
HPV 6 and 11 associated
Soft neoplasms; fibrovascular core covered with stratified squamous epithelium
Contact with opposing vocal cord may cause trauma or hemoptysis (coughing up blood)
Gonococcal Pharyngitis ST
history
PE/presentation
next steps
His : orogenital sexual activity
Pharyngeal exudate
bilateral cervical lymphadenopathy
gram stain and gonorrhea culture
Herpangia ST
aka
history
PE/presentation
next steps
coxsackievirus
more common in children, immunosuppressed
painful throat, fever, malaise
Lymphadenopathy
soft grey papulovesicular lesions on the soft palate and pharynx
serology
Aphthois stomatis ST
aka
history
PE/presentation
next steps
canker sores
oral trauma
painful ulcers varying in size
abscence of other symptoms
shallow ulcers
yellow membrane and red halo
no fever or nodes
no next steps
Fusospirochetal infection ST
aka
history
PE/presentation
next steps
Vincent angina
Poor oral health
painful ulcers
foul breath
bleeding gums
grey necrotic ulcers on gingival margins
gram stain reveals spirochetes
Herpes Simplex ddx ST
history
PE/presentation
next steps
trauma to mucosa, pain,
perioral lesions
lymphadentitis (enlargment of 1 or more nodes)
viral culture
Candidiasis ST
history
PE/presentation
next steps
yeast infection
immunosupressed , Abx use, diabetes
curdlike white plaques that bleed when scraped off
KOH prep
