Strep Pharyngitis and Epiglottitis Flashcards
Lemierre's syndrome too
sore throat (100%) , fever (90%) , odynophagia and dysphagia (94%) dysphonia (65%) stridor (30%) drooling (40%)
features of epiglottis
what is epiglottitis
cellulitis of epiglottis that results from bactermia or direct bacterial invasion from the posterior nasopharynx
what testing/imaging should be done in suspected epiglottis and what do you look for?
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
diagnosis of epiglottis
direct visualization of an erythematous and edematous epiglottis on laryngoscopy but pharynx should be examined carefully to avoid causing airway obstruction
common causes of epiglottitis
H influenzae, beta hemolytic strept, strep penumoniae and staph
treatment of epiglottis
IV ceftriaxone and vancomycin
rapid antigen testing for group A strep is
85-90% culture for strep is gold standard with a sensitivity of 95%
incidence of group A strep in adults
<10%
Centor Criteria
If allergic to penicillin give azithromycin 500 followed by 250 mg for four more days.
Abx prophylaxis for secondary prevention of recurrent rheumatic fever
this is given to anyone who has ever had rheumatic fever.
if pts have had rheumatic fever in the past and now has symptoms of strep throat, what to do?
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.
in pt with previous rheumatic fever now has group A strep pharyngitis what do they need to get?
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)
what is the feared complication in pts who have had Strep throat (pharygnitis)
development of rheumatic fever.
Rheumatic fever can result in mitral stenosis.
needs to have long term abx prophylaxis.
rheumatic fever is
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
Indications for antibiotic therapy for suspected rhinosinusitis.
Evaluation and management based on Centor criteria
What is Lemierre’s syndrome?
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.
rheumatic fever prophylaxis
IM long acting penicillin G benzathine every 3-4 weeks and therapy duration is determined by severeity of underlying rheumatic heart disease.
fever, arthralgias, migratory arthritis, and subcutaneous nodules and mitral regurg murmur and elevated ESR in a patient who recently emigrated
This is acute rheumatic fever. This develops 2-4 weeks after pharyngeal infection with group A beta hemolytic strept.
How to diagnose acute rheumatic fever?
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
Centor criteria states that if
>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
Lemierre’s syndrome presentation
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)
Diagnosis of Lemierre’s syndrome.
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. )
Why do we never get anti-streptolysin (ASO) titers for possible group A strep pharyngitis?
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.
Acute rheumatic fever is
what is pharyngitis?
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.
