URI Flashcards
most common virology of common cold
rhinovirus- 30-50%
other virologies of common cold
coronavirus, influenza, parainfluenza, RSV) respiratory synctial virus, adenovirus, enterovirus (coxsackie)
transmission of cold
hands, droplet (sneeze/cough), large particle droplet (close contact), fomites
daycare, underlying chronic condition, immunodeficiency, dec sleep/ sleep disorders, malnutrition, exposure to smoke are risk factors for
cold
RHINORRHEA, NASAL CONGESTION, sore throat, non productive cough, malaise, mild HA, LG fever, self limit in 7-10 days
sxs of common cold
imp sxs of common cold
rhinorrhea, nasal congestion
nasal mucosal swelling, nasal discharge (clear/ water/ purulent), conjunctival infxn, pharyngeal erythema (mild), no pulmonary findings/ adenopathy
signs of common cold
dx of cold based on
clinical, reported sxs, observed signs
type ___ flue subtypes more dangerous
A
cold tx
self limiting, rest, fluids, handwashing
NO ABX, symptomatic treatment
guaifenesin and guaifeniesin with dextromethorphan
robitussin and robtiussin DM
expectorants/ antitussives good for common cold
acute rhinosinusitis, AOM, acute asthma attack, PNA
complications of common cold
transmission of flu
aeorosolized droplets (cough/sneeze), hand 2 hand contact, incubation 1-4 days
imp symptoms of flue
abrupt onset, fever, myalgia, sore throat (can be severe)
chills, malaise, HA, cough (non-productive), sore throat, nasal discharge, abrupt onset, fever, myalgia,
sxs of flu
flushing, hot/ dry skin, unremarkable post pharynx, mild cervical LAD, negative chest exam
signs of flu
people who are over ___ or under ___, but especially under ___ are at high risk of flue
over 65, under, 5, especially under 2
people at high risk of flu
chronic illnesses, immunosuppressed, pregnant/ post -artum, healthcare workers, resident of nursing homes, native americans, BMI 40+
flu tests should be done within ___ of illness
3-4 days
flu screening test- nasal pharyngeal aspirate/swab, 15 minutes for results, SOME can distinguish b/w type A and B
RAT
Rapid Antigen Tests
flu screening test- nasal swab/washing, 1-4 hours for results, CAN differentiate b/w types A andB
immunofluorescence
flu screening test- NP swab, 15-30 mins for results, high sensitivity/ specificity, distinguishes b/w type A/B
rapid molecular assay
flu screening test- NP swab/sputum, 1-8 hours for results, MOST sensitive and specific for flu type/subtype
RT- PCR
Reverse transcriptase polymerase chain reaction
gold standard for lab diagnosis of flu
viral cultures
not for initial clinical management of flu but to confirm screening, takes 3-10 days
viral tissue cell culture
tonsillar exudates, tender anterior cervical adenopathy, fever by hx, absence of cough
steptococal pharyngitis centor criteria; patients with 3/5 should undergo testing for GAS
when should RT-PCR / viral flu cx be ordered if negative
RAT/ immunofluorsecence ab staining + high community flu rates
when should RT-PCR / viral flu cx be ordered if positive
RAT/ immunofluorescence + low community influenza rates
test pt for RT-PCR / viral cx be ordered if they are exposed to ____ and worry about novel flu ___
pigs/ poultry, flu A
acute flu generally improves in
3-7 days
cough and malaise with flu may persist for
1-2 weeks
when to give an antiviral with flu
hospitalization, progressive/ severe/ complicated illnesses, HIGH RISK OF COMPLICATIONS
administer antiviral for flu within ___, it shortens course by ___
24-30 hours, 1-2 days
pharm tx for influenza A/B
oseltamivir, zanamivir, peramivir (all are neuraminidase inhibitors)
dose for oseltamivir
75 mg po BID x 5 days
dose for zanamivir
10 mg (2 inhalations) BID x 5 days
dose for peramivir
600 mg IV x 1
flu drugs are ___ but you give if
Category C (so you dont give to pregnant), but you give if suspect flu A
zanamivir is contraindicated in patients with
asthma/ chronic respiratory conditions
PNA, rhinosinusitis, OM, myositis, rhabdomyolysis, CNS involvement, cardiac are complications of
flu
flu vaccines are indicated for everyone ___ months old
over 6
IM trivalent inactivated flu vaccine protects against
A H1N1, A H3N2, flu B
IM quadrivalent flu vaccine protects against
A H1N1, A H3N2, flu B and another flu B
takes ___ after vaccine for antibodies to develop
2 weeks
for ages 18-49 give ___ flu vaccine
standard dose inactivated (trivalent/ quadrivalent)
for age 65+ give ___ flu vaccine
high dose trivalent
give live attenuated vaccine to
not pregnant b/w 2 and 49
best month to give vaccine
october
contraindications of flu vaccine
current illness/ hx of guillain barre (w/in 6 weeks of prev flu vaccine)/ hx of allergic rxn to vaccine
most common viral origins of pharyngitis
rhinovirus, adenovirus, parainfluenza, influenza
pharyngitis may occur as ___ with ___
common cold with rhinorrhea and cough
viruses are ___ likely to cause pharyngeal exudate
less; exceptions- adenovirus/ mononucleosis
tx for viral pharyngitis
hydration, antipyretics/ anaglesics, rest, “magic mouthwash”
tx for HSV pharyngitis
acyclovir, famiclovir
tx for HIV pharyngitis
referral to infectious disease specialist for retroviral therapies
group A stretocococcus (GAS) bacterial pharyngitis causes
5-15% adults, 20-30% of kids
C trachomatis (bacterial pharyngitis) associated with
oral sex
N. gonorrhea (bacterial pharyngitis) associated with
oral sex
M. pneumoniae (bacterial pharyngitis) associated with
lower resp infxn and HA
H. influenza (bacterial pharyngitis) associated with
pediatric age group
C. diphtheriae (bacterial pharyngitis) is recognized by
diphtheria (gray exudate tightly adherent to throat, nasal passageway)
(creamy, white/ yellow plaques) are seen with pharyngitis
oral candidasis
sore throat, odynophagia, fever, malaise, anorexia, arthralgias, myalgias, nausea, vomitting, swollen glands
streptococcal pharyngitis sxs
pharyngeal erythema, tonsillar hypertrophy, purulent exudate, tender and/ or enlarged anterior cervical lymph nodes, palatal petechiae
streptococcal pharyngitis signs
steptococal pharyngitis centor criteria
tonsillar exudates, tender anterior cervical adenopathy, fever by hx, absence of cough; patients with 3/5 should undergo testing for GAS
gold standard for pharyngitis dx
throat cx
throat culture for pharyngitis can be ___ or ___
bacterial or viral
pharyngitis dx for group A strep
rapid antigen detection test
if pt meets centor criteria (w/ negative RADT) treat ____
empirically while waiting cx
first line tx for GAS pharyngisits
- penicillin V 500 mg PO TID x 10 days
- amoxicillin 500 mg BID x 10 days
- pencillin G benzathine 1.2 million units IM
- cephalexin 500 mg PO BID x 10 days
tx for pharyngitis if pt has a penicillin allergy
azithromycin, clindamycin, clarthromycin
in addition to abx, treat pharyngitis with
supportive care, lozenges, NSAIDs, acetaminophen
acute rheumatic fever, post-strep glomerulonephritis, peritonsillar abscess, OM, rhinosinusitis, bacteremia, PNA, toxic shock syndrome, SCARLET FEVER
complications of pharyngitis
rash, desquamation, pastia’s lines, facial flushing w/ circumoral pallor, “strawberry tongue”, can predispose for acute rheumatic fever
scarlet fever
scarlet fever can predispose for
acute rheumatic fever
strep pharyngitis is no longer contagious after ___ and clinical sxs improve after ___ after initiating abx tx and may return to work/school/daycare
3-4 days, 24 hours
most common deep neck infx in children and adolescents
peritonsillar abscess
polymicrobial etiology, mainly S. pyrogenes (GAS), S. aureus, mixed respiratory anaerobes and H. influenzae
peritonsillar abscess etiology
in ____ there is tissue infxn b/w palatine tonsil capsule and pharyngeal muscles with no pus; in ___ there is pus b/w tonsil capsule and pharyngeal muscles and it progresses to ___
in CELLULITIS there is tissue infxn b/w palatine tonsil capsule and pharyngeal muscles with no pus; in ABSCESS there is pus b/w tonsil capsule and pharyngeal muscles and it progresses to CELLULITIS
unilateral severe sore throat, drooling, trismus, fever, neck swelling/pain, ipsilateral ear pain, fatigue, anxiety, irritability, decrease PO intake
peritonsillar abscess sxs
trismus
spasm of internal pterygoid muscle
deviated uvula pushed to the opposite side of swollen tonsil, fullness of soft palate with palpable fluctuance, cervical lymphadenopathy, bilateral peritonsillar abxcess if uvula displaced anteriorly, hot potato/ muffled voice
peritonsillar abscess signs
dx for peritonsillar abscess
- clinical
- labs (CBC, electrolytes, throat cx)
- can get a CT to r/o infxn to danger zone but must use contrast
tx for peritonsillar abscess (non-abx)
- monitor airway
- drain (aspirate, tonsillectomy, OR)
- supportive care (FLUIDS, pain control)
- +/- glucocorticoids
parenteral abx tx for peritonsillar abscess
ampicillin-sulbactam or clindamycin (consider vanco if high rates of MRSA)
oral abx tx for peritonsillar abscess
amoxiciiln-clavulanate or clindamycin x 14 days
etiology of epiglottitis
H. influenzae
drooling, stidor, severe sore throat, no cough, toxic appearance
epiglottitis
consider ___ in unvaccinated kids and older adults
epiglottitis
___ is a danger of airway obstruction, rapid course
epiglottitis
epiglottitis tx
hospitalization, intubation, antibiotics
imaging of epiglottits
lateral neck x-ray: “thumb sign”, CT/MRI
etiology of severe tonsillopharyngitis
EBV, HSV1/2, coxsackie virus, adenovirus, C. diphtheria, N. gonorrhea
pharyngeal edema, exudates, tonsillar hypertrophy
severe tonsillopharyngitis
dx for severe tonsillopharyngitis
monospot and viral/bacterial cx, CT w contrast/MRI
tx for severe tonsillopharyngitis
based on etiology
trauma (chicken bone), recent instrumentation with secondary bac infxn
retropharyngeal abscess/ cellulitis
prominent neck stiffness, minimal peritonsillar findings, trismus is rare
retropharyngeal abscess/ cellulitis
extremely serious, can extend to the mediastinum
retropharyngeal abscess/ cellulitis
dx and tx of retropharyngeal abscess/ cellulitis
CT/MRI w/ contrast, airway managment, abx, image guided aspiration of abscesses
ludwigs angina
submandibular space infxn
due to odontogenic infxn
submandibular space infxn
no trismus, elevated tender oropharynx, “woody” indurated submandibular area w/ possible crepitus
submandibular space infxn
dx and tx of submandibular space infxn
CT/MRI w/ contrast, airway managment, abx, abscess drainage
most common etiology of laryngitis
viruses (often associated with URI)
bacterial etiologies of laryngitis
Streptococci species, moraxella catarrhalis, H. influenzae
vocal abuse (sing/shout), intubation, toxic exposure (smoke, radiation), GERD, vocal cord nodules, laryngeal polys, carcinoma of vocal cords, neurologic dysfxn
non infectious causes of laryngitis
key symptom of laryngitis
hoarseness
dysphonia, URI sxs (rhinorrhea, congestion, sore throat, cough), hoarsensess
sxs of laryngitis
nasal edema, congestion, benign posterior pharynx, laryngeal erythema/ edema, vascular engorgement of vocal cords, nodules, ulcerations
signs of laryngitis
dx of laryngitis
- based on hx and PE,
- hoarseness > 2 weeks in abscense of URI then refer to ENT for laryngoscopy
- hoarseness with URI can last 2-3 weeks
tx for laryngitis
treat underlying cause, voice rest, humidification, hydration, d/c smoking, refer to ENT prn
__ out of __ Americans get rhinosinusitis annually
1 out of 7
highest incidence of rhinosinusitis
45-64 y/o
ARS
acute rhinosinusitis
purulent nasal drainage AND nasal obstruction and or facial pain, pressure, or fullness
acute rhinosinusitis
acute rhinosinusitis sxs last
<4 weeks
subactute rhinosinusitis sxs last
4-12 weeks
chronic rhinosinusitis sxs last
> 12 weeks
recurrent actue rhinosinusitis is ___ episodes of ARS/ year
4 +
most common etiology for ARS is
viral (AVRS)- rhinovirus, influenza, parainfluenza
ABRS (acute bacterial rhinosinusitis) etiology
(only 0.5-2% of ARS)
- strep pneumoniae
- H. influenzae
- moraxella catarrhalis
beyond infectious causes, ARS can also be associated w/
allergies, tumors, polyps, deviated nasal septum, foreign bodies
LG fever, congestion/ discharge, facial pain/pressure, fatigue, cough, maxillary tooth discomfort, ear pressure/ fullness, HA
sxs of ARS
** degree varies b/w AVRS and ABRS
purulent drainage in nose/ post pharynx, nasal mucosal edema, edema over involved cheekbone/ periorbital area, tenderness to percussion of upper teeth, sinus tenderness to palpation, opaque transillumination of frontal or maxillary sinuses
signs of ARS
radiography is ___ for AVRS diagnosis
not indicated
cultures are ___ for AVRS
not indicated
diagnosis of AVRS
clinical, < 10 days of sxs that are not worsening, plain sinus films (limited use)
tx for AVRS
supportive (analgesics, irrigation, mucolytics, intranasal decongestants, glucocorticoids)
classic presentation of ABRS is
prior hx of URI and AVRS
viral infxn leading to mucosal edema and sinus inflammatoin, decreased drainage of thick secretions leading to obstructed sinus ostia
leads to entrapment of bacteria and secondary ABRS following AVRS
ABRS diagnosis according to infectious disease society of american (IDSA)
persistent sxs/ signs > 10 days w/ no improvement OR onset of severe sxs OR viral URI that lasted 5-6 days, was improving then “double worsened”
fever > 102, purulent nasal drainage, facial pain lasting at least 3-4 consecutive days at the beginning of illness
severe sxs associated with ABRS and indicated by IDSA
pts at higher risk for abx resistance
65 y/o + severe infxn temp 102 + recent hospitalization immunocompromised comorbidities recent abx use (in past month)
first line tx for ABRS
amoxicillin-clavulanate- 500 mg/TID
use first line tx for ABRS when patients are/ are not at risk for abx resistance
are not
tx for ABRS if pt has a penicillin allergy
- doxycycline 100 mg BID
- levofloxacin 500 mg QD
- moxifloxacin 400 mg QD
duration of tx for 1st line tx recommended for ABRS
5-7 days
second line tx for ABRS is used when
no response/ worsening sxs OR HIGH RISK OF ABRS RESISTANCE
second line tx for ABRS
amoxicillin-clavulanate - 2000/125 mg BID
when high risk of ABRS resistance use
second line tx
duration of tx for 2nd line tx of ABRS
7-10 days
complicated ABRS
spread of infxn to the CNS/ orbit/ surrounding tissues, may be associated with persistent, high fevers (>102)
usually frontal, with doughy edema, severe HA
osteomyelitis (complication of ABRS)
severe HA, AMS, +/- nuchal rigidity
meningitis/ brain abscess/ epidural abscess (complication of ABRS)
periorbital edema/ inflammation/ erythema, abnormal extraocular movements, proptosis, vision changes (diplopia/ dec. acuity)
periorbital and/or preseptal or orbital cellulitis (complication of ABRS)
radiologic studies are indicated w/ ABRS if
suspect complicated ABRS
radiologic studies ordered w/ ABRS
CT w/ contrast & MRI
gold standard dx for complicated ABRS
sinus aspirate
tx for complicated ABRS
admit to hospital, URGENT ENT/ID consult
relating to ABRS: severe infxn, need urgent endoscopy/cx/surgical biopsy, anatomic defect obstructs, immunocompromised, failure to respond to 1st and 2nd line tx, multiple recurrent episodes, allergic rhinitis leading to ABRS in candidate for immunotherapy, chronic rhinosinusitis
are indications for ENT referral/ consult
CRS
chronic rhinosinusitis
risk factors:
allergic rhinitis, chronic irritant exposure, defects in mucocilliary clearance (CF), presence of immunodeficiency/ autoimmune/ inflammatory disease, anatomical abnormality predisposing to sinus obstruction, latrogenic
risk factors for CRS
latrogenic
multiple sinus surgeries
4 cardinal sxs of CRS in adults
- mucopurulent nasal drainage
- nasal obstruction and congestion
- facial pain/ pressure/ fullness
- reduction/ loss of sense of smell
4 cardinal sxs of CRS in kids
- mucopurulent nasal drainage
- nasal obstruction and congestion
- facial pain/ pressure/ fullness
- cough
diagnostic criteria of CRS
2/4 of cardinal sxs
AND infection for 12+ weeks
PLUS sinus mucosal disease w/ mucosal thickening and opaque paranasal sinuses OR mucosal inflammation, nasal polyps, edema, and purulent mucus
viral pharyngitis with vesicles on erythematous base
HSV1 and HSV2
to dx viral pharyngitis etiology as HSV1/2
- viral cx, tzanck prep: multinucleated giant cells
- serology: HSV antibodies
viral pharyngitis with sore throat, pharyngeal erythema, tonsillar exudates, enlarged cervical lymph noes or diffuse LAD, splenolmegaly
Mononucleosis aka Epstein-Barr Virus (EBV)
to dx viral pharyngitis etiology as mono
- Monospot
- CBC w/ diff (increased atypical lymphocytes)
tx for viral pharyngitis caused by mono
supportive, avoid contact sports
duration of mono
2-4 weeks; contagious up to 3 months!
viral pharyngitis with acute gingivitis, painful oropharyngeal ulceration (sharply demarcated), febrile illness like mono, painless generalized lymphadenopathy, not tonsillar enlargement, no pharyngeal exudates, +/- maculopapular rash, fatigue
HIV
dx for recurrent or treatment resistant rhinosinusitis
NON CONTRAST CT, referral to ENT for endoscopy/ sinus aspirate cx
nasal saline lavage, intranasal corticosteroids, oral corticosteroids, oral antimicrobials, antihistamines, topical/ systemic antifungals, endoscopic sinus surgery
tx for CRS
