Upper Respiratory Tract Infections

Question 1

Pharyngitis causes:

Answer 1

Usually viral (rhinovirus or coronavirus). May result from group A streptococcus, or atypicals. Most important to identify STREPTOCOCCAL pharyngitis.

Question 2

Viral pharyngitis signs and symptoms:

Answer 2

Nasal discharge
Sore “scratchy” throat
Non-productive cough with post-nasal drip
Red nares with clear discharge
Mucous on posterior pharyngeal wall, but no exudate.
No or minimal fever

Question 3

Viral pharyngitis transmission:

Answer 3

Usually hand-to-hand (for rhinovirus), but others via aerosol
Virus may persist on fomites for several hours
Saliva is not an efficient means of transmission

Question 4

Viral pharyngitis pathophysiology and recovery:

Answer 4

Most symptoms due to immune response
Clinical recovery is most likely due to interferon release by the nasal epithelium
Physiological stress is correlated with cold infection

Question 5

Viral pharyngitis treatment:

Answer 5

Intranasal ipratropium bromide (reduces nasal discharge)
Ibuprofen/warm saline gargles
Antitussives (dextromethorphan, guiafenesin, or codeine)
Avoid aspirin use in children due to possibility of Reye’s syndrome

Question 6

Viral pharyngitis complications:

Answer 6

Sinusitis
Acute otitis media
Lower respiratory tract disease

Question 7

Group A strep pharyngitis signs and symptoms:

Answer 7

Abrupt onset
Severe sore throat, pain with swallowing
Systemic illness with feverishness and malaise
Nasal congestion and cough (only in 50%)
Temperature 100-104
Diffuse redness of pharynx and tonsils
Tonsillar exudates (patchy or confluent)
Enlarged, tender anterior cervical nodes

Question 8

Group A strep pharyngitis diagnosis:

Answer 8

Important to prevent sequelae such as rheumatic fever.
If tonsillar exudates, enlarged tender cervical lymph nodes and temperature >100 are present, there is a 42% chance of the patient having the infection.
Culture on blood agar
Rapid enzyme immunoassay

Question 9

Group A strep pharyngitis treatment:

Answer 9

Begin antibiotics (oral penicillin V) within 9 days of symptoms to prevent rheumatic fever.
Erythromycin or another macrolide in individuals allergic to penicillin.

Question 10

Infectious mononucleosis signs and symptoms:

Answer 10

Exudative pharyngitis/laryngitis
Fever, headache, malaise, and fatigue
Onset: abrupt or with several day prodrome
Diffuse cervical adenopathy
Splenomegaly in 50%

Question 11

Infectious mononucleosis etiology:

Answer 11

Usually EBV. May be CMV, HIV, and toxoplasma.

Persists in oropharynx for 18 months after clinical recovery

Question 12

Infectious mononucleosis diagnosis:

Answer 12

Hematological findings include atypical T-cells on peripheral smear.
Thrombocytopenia in 50%.
Positive heterophile antibody test with EBV

Question 13

Influenza signs and symptoms:

Answer 13

Abrupt onset
Systemic symptoms predominate (headache, high fevers, myalgias)
Pharyngitis is minimal.
Small, tender, cervical adenopathy common

Question 14

Influenza pathogenesis and etiology:

Answer 14

Influenza A and B virus
Transmitted by aerosol droplets (1 day prior to onset to 5-10 days after resolution of fevers)
Interferon is active in the recovery process before the serum or secretory antibody is detected.

Question 15

Influenza diagnosis:

Answer 15

Clinical diagnosis in setting of epidemic has high PPV
Rapid assay (ELISA) on nasopharyngeal aspirate
Nasal or throat swab

Question 16

Influenza treatment and prevention:

Answer 16

Supportive. Amantadine/rimantadine reduce symptoms by 50%, neuraminidase inhibitors (oseltamivir/zanamivir).
Vaccine has 80-90% efficacy.

Question 17

Acute bronchitis:

Answer 17

An acute inflammatory condition of the tracheobronchial tree that does not involve the pulmonary parenchyma.

Question 18

Acute bronchitis signs and symptoms:

Answer 18

Persistent cough for days, +/- sputum production, +/- fevers, lung exam reveals crackles and wheezes, but no consolidations.

Question 19

Acute bronchitis causes:

Answer 19

Usually viral (rhinovirus).
Mycoplasma pneumoniae and Chlamydia pneumoniae are common.
Bordatella pertussis is relatively rare.

Question 20

Mycoplasma bronchitis symptoms:

Answer 20

Cough (dry and hacking at first, followed by production of mucoid sputum, then purulent sputum). Usual duration is 2 weeks.
Rhonchi and coarse rales commonly heard on lung exam. Low grade fever.
Wheezes may be induced, most commonly in atopic or asthmatic individuals.

Question 21

Bronchitis diagnosis:

Answer 21

Important to distinguish from pneumonia.
Patients with pneumonia are usually more ill.
Chest radiography will reveal either nothing or peribronchial cuffing with bronchitis, but an infiltrate is usually present with pneumonia.
Serum IgM immunoassay is useful for M. pneumoniae.

Question 22

Bronchitis treatment:

Answer 22

Treat cough symptomatically with dextromethorphan or codeine.
Bronchodilators or steroids for wheezing.
Erythromycin or another macrolide for M. pneumoniae or C. pneumoniae.

Question 23

Acute sinusitis:

Answer 23

Infection of one or more of the perinasal sinuses. May be viral, bacterial, or fungal.
The sinuses are lined with ciliated, pseudo-stratified epithelium which is covered by a thin mucus blanket. The sinuses are sterile under normal conditions, even though there is a direct connection to the nasopharynx.
Sinusitis results from obstruction of the ostia during a viral URI.

Question 24

Acute sinusitis causes:

Answer 24

Streptococcus pneumoniae

Haemophilus influenza

Question 25

ACABS signs and symptoms:

Answer 25

Overlap with URI. Persistent cough, purulent nasal discharge, severe temporal or retro-orbital headache (sphenoid sinusitis). Chronic sinusitis by anaerobes may present with malodorous breath.

Question 26

ACABS diagnosis:

Answer 26

Gold standard is aspiration and culture.
Diagnosis is often based on history and physical exam findings alone.
Diagnosis may be radiographically supported, which reveals an air-fluid level with a flat meniscus (usually not indicated however).
Must distinguish from VRS (viral respiratory syndrome): usually by presence of facial pain, fever, erythema and/or swelling.

Question 27

ACABS complications:

Answer 27

Subdural empyema, brain abscess, meningitis, recurrent or chronic sinusitis. However, most cases resolve spontaneously.

Question 28

ACABS treatment:

Answer 28

Amoxicillin-clavulanate, cefuroxime, cefpodoxime, or new quinolones.
Antihistamines and NSAIDs for symptomatic benefits.