Strep Pharyngitis and Epiglottitis

Question 1

sore throat (100%) , fever (90%) , odynophagia and dysphagia (94%) dysphonia (65%) stridor (30%) drooling (40%)

Answer 1

features of epiglottis

Question 2

what is epiglottitis

Answer 2

cellulitis of epiglottis that results from bactermia or direct bacterial invasion from the posterior nasopharynx

Question 3

what testing/imaging should be done in suspected epiglottis and what do you look for?

Answer 3

lateral neck XRAY only done in pts in stable pts without impending airway obstruction (stridor)

Look for XR findings of epiglottis with swollen and enlarged epiglottis >8 mm in adults (Thrumbprint sign) and loss of vallecular air space and thickened arepiglottis folds >7 mm in adults

Question 4

diagnosis of epiglottis

Answer 4

direct visualization of an erythematous and edematous epiglottis on laryngoscopy but pharynx should be examined carefully to avoid causing airway obstruction

Question 5

common causes of epiglottitis

Answer 5

H influenzae, beta hemolytic strept, strep penumoniae and staph

Question 6

treatment of epiglottis

Answer 6

IV ceftriaxone and vancomycin

Question 7

rapid antigen testing for group A strep is

Answer 7

85-90% culture for strep is gold standard with a sensitivity of 95%

Question 8

incidence of group A strep in adults

Answer 8

<10%

Question 9

Centor Criteria

Answer 9

If allergic to penicillin give azithromycin 500 followed by 250 mg for four more days.

Question 10

Abx prophylaxis for secondary prevention of recurrent rheumatic fever

Answer 10

this is given to anyone who has ever had rheumatic fever.

Question 12

if pts have had rheumatic fever in the past and now has symptoms of strep throat, what to do?

Answer 12

with repeat exposure to group A strep, pts who have prior rheumatic fever are at great risk for recurrent rheumatic fever and consequent progression of rheumatic heart disease .

Bottom line: anyone with rheumatic heart diseae needs continuous IM penicillin G benzathine abx prophylaxis long term.

Question 14

in pt with previous rheumatic fever now has group A strep pharyngitis what do they need to get?

Answer 14

continuous antibiotic prophylaxis to prevent GAS pharyngitis.

Give long acting penicillin G benzathine IM every 3-4 weeks for secondary prevention of rheumatic fever recurrence and antibiotic prophylaxis depends on severity of underlying rheumatic heart disease (presence of absence of carditis or valvular dx)

Ist dose would treat any current GAS colonization or infection.

(doesn’t matter if pt is 29 and has to get abx until 40 yrs old)

Question 15

what is the feared complication in pts who have had Strep throat (pharygnitis)

Answer 15

development of rheumatic fever.

Rheumatic fever can result in mitral stenosis.

needs to have long term abx prophylaxis.

Question 17

rheumatic fever is

Answer 17

Complication of missed group A beta strep pharyngitis that caused a sequalae. Can reoccur even after treated. Longterm causes mitral stenosis. If re-encounters Group A strep pharyngitis or gets reoccurence of rheumatic fever can have progression into heart failure so anyone with rheumatic fever gets prophylaxis long term.

See the classic JONES criteria:

Joint - arthralgias

Carditis - <3 for “O”

Nodulars

Erythema marginatum - rash

Syndeham chorea

Question 18

Indications for antibiotic therapy for suspected rhinosinusitis.

Answer 18

Question 19

Evaluation and management based on Centor criteria

Answer 19

Question 21

What is Lemierre’s syndrome?

Answer 21

infection caused by fusobacterium necrophorum or a anerobic bacteria.

Presents in young healthy adults and initially is a pharyngitis or a dental infection and infection can improve spontaneously then extend to the lateral pharyngeal space and include the carotid shealth and result in a septic thrombophlebitis of the IVC. This is now called Lemierre’s syndrome.

Question 22

rheumatic fever prophylaxis

Answer 22

IM long acting penicillin G benzathine every 3-4 weeks and therapy duration is determined by severeity of underlying rheumatic heart disease.

Question 23

fever, arthralgias, migratory arthritis, and subcutaneous nodules and mitral regurg murmur and elevated ESR in a patient who recently emigrated

Answer 23

This is acute rheumatic fever. This develops 2-4 weeks after pharyngeal infection with group A beta hemolytic strept.

Question 24

How to diagnose acute rheumatic fever?

Answer 24

Need positive throat culture for GAS (negative 75% of pts with acute rheumatic fever)

Positive rapid streptococcal antigen test

elevated or rising anti-streptolysin O (ASO) antibody titer)

Diagnosis of acute rheumatic fever is based on evidence of GAS infection and 2 major or 1 major and 2 minor manifestations of Jone’s criteria

Question 27

Centor criteria states that if

Answer 27

>2 criteria should bet rapid strep antigen testing (RSAT) which has high specificity.

Some clinicians will treat GAS pharyngitis empirically if all 4 criteria are met. Some people

Question 29

Lemierre’s syndrome presentation

Answer 29

see history of pharyngitis, develop neck pain and neck swelling and persistent fever despite appropriate antibiotics

can see septic pulmonary emboli and other embolic phenomenon (arthritis and osteomyelitis)

Question 30

Diagnosis of Lemierre’s syndrome.

Answer 30

CT showing internal jugular vein thrombophlebitis and is confirmed with blood or tissue cultures

Treatment is 4 weeks of antibiotics - that have anaerobic coverage, beta lactamase with beta lactamase inhibitors (ampicillin-sulbactam (unasyn) and clindamycin, and carbapenems. )

Question 31

Why do we never get anti-streptolysin (ASO) titers for possible group A strep pharyngitis?

Answer 31

because ASO takes 2-4 weeks to become positive after pharyngitis and it not helpful for initial evaluation

second, ASO titers remains positive/elevated for months so only tells you of a prior past infection.

Question 32

Acute rheumatic fever is

Answer 32

Question 33

what is pharyngitis?

Answer 33

inflammation of the pharynx and presents as sore throat htat owrsens with swallowing

symptoms generally last <1 week and most commonly from the viral causes. common cold

see cough, conjunctivitis, coryza, hoarseness and oral ulcers.

treatment is conservative with analgesics (NSAIDs or acetaminophen), lozenges, topical sprays and increased environmental humdity.