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Infectious Diseases (4th year) > URI - Sore Throat, Earache, and Upper Respiratory Symptoms > Flashcards

URI - Sore Throat, Earache, and Upper Respiratory Symptoms Flashcards

1
Q

What is the most common reasons for visit to primary care providers?

A

Infection of the upper respiratory tract (URIs)

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2
Q

URI =

A

upper respiratory tract

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3
Q

How are the URIs usually classified?

A

Mild

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4
Q

What is the leading cause of time lost from work or school?

A

URIs

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5
Q

What is the the leading diagnoses for which antibiotics are prescribed on an outpatient basis?

A

URIs are the leading diagnoses for which antibiotics are prescribed on an outpatient basis

-> it has contributed to the rise in antibiotic resistance among community aquired pathogens (i.e. S. pneumoniae)

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6
Q

What is the percentage of the URIs that are cause by bacteria?

A

A minority (~25%) of cases are caused by bacteria

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7
Q

What are most URIs caused by?

A

viruses

  • Distinguishing patients with primary viral infection from those with primary bacterial infection is difficult
  • Signs and symptoms of bacterial and viral URIs are typically indistinguishable.
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8
Q

How are acute infections usually diagnosed?

A

acute infections are usually diagnosed on clinical grounds

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9
Q

Nonspecific infections of the upper respiratory tract?

A
  • broadly defined group of disorders that constitutes the leading cause of ambulatory visit
  • no prominent localizing featrures
  • specific diagnostic tests are generally unnecessary
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10
Q

Nonspecific infections of the upper respiratory tract has other names including:

A
  • acute infective rhinitis
  • acute rhinopharyngitis
  • common cold
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11
Q

nearly all URIs are caused by…..

A
  • viruses spanning multiple virus families
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12
Q

What is the most common cause of URI?

A

The most common cause (30%-40%) of URI is Rhinovirus which has at least 100 immunotypes

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13
Q

What are other causes of URI:

A
  • influenza virus (3 types)
  • parainfluenza virus (4 types)
  • adenovirus (47 types)
  • RSV
  • Enterovirus
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14
Q

Where are the Nonspecific infections of the upper respiratory tract localized?

A

lack of localization in one particular anatomical area, such as the sinuses, pharynx, lower airway

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15
Q

For how long does the Nonspecific infections of the upper respiratory tract last?

A

it is usually self-limited catarrhal syndrome with a median duration of 7 days (range 1-10 days)

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16
Q

The same viruses -

A

variety of signs and symptoms

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17
Q

What are the principal signs of Nonspecific infections of the upper respiratory tract?

A
  • rhonrrhea (+/- purulence)
  • nasal congestion
  • cough
  • sore throat
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18
Q

What are the other manifestation Nonspecific infections of the upper respiratory tract?

A
  • fever
  • malaise
  • sneezing
  • lymphadenopathy
  • hoarseness
  • fever (more common among the children)
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19
Q

What are the finding of Nonspecific infections of the upper respiratory tract on physical examination?

A

nonspecific

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20
Q

0.5-2% of colds are complicated by…..

A

secondary bacterial infection

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21
Q

Purulent secretions from the nares or throat are (without other clinical findings)…..

A

often misinterpreted as an indication of bacterial sinusitis or pharyngitis

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22
Q

Nonspecific infections of the upper respiratory tract - treatment:

A
  • DO NOT USE ANTIBIOTICS!
  • Symptomized treatment
  • Non-steroidal anti-inflammatory drugs (e.g. ibuprofen), decongestants
  • Zink, vitamin C, echinacea - no consistent benefit in the treatment of nonspecific URI
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23
Q

Rhinosinusitis -

A

Inflammatory condition involving the nasal sinuses (often more than 1)

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24
Q

Which sinus is the most commonly involved in infections of the sinus?

A

maxilary

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25
Q

Which sinuses are involved in the infections of the sinuses?

A

maxillary>ethmoid>frontal>sphenoid

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26
Q

For how long does acute sinusitis last?

A

<4 weeks duration

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27
Q

Why is antibiotics prescribed very frequently when it comes to the infection of the sinuses?

A

differentiating bacterial from viral sinusitis on clinical ground is difficult, that´s why antibiotics are prescribing very frequently (85%-98% of cases)

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28
Q

What are the non-infectious causes of sinusitis?

A
  • allergic rhinitis
  • barotrauma (deep-sea diving)
  • exposure to chemical irritants
  • granulomatous disease
  • tumours
  • cystic fibrosis
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29
Q

What is the most common reason for sinusitis?

A

viral (rhino-, influenza-, and parainfluenzaviruses) is much more common than bacterial sinusitis (S.pneumoniae and H.influenzae - up to 60% and M.catarrhalis - 20%, S.aureus, MRSA, anaerobes)

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30
Q

What are the common causes of nosocomial sinusitis (after surgery, tracheal intubation etc):

A
  • s.aureus
  • p.aeruginosa
  • s.marcescens
  • k.pneumoniae
  • enterobacter spp
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31
Q

Who usually gets fungal sinusitis?

A

fungal sinusitis more common in immunocompromised patients, usually more aggressive, invasive, life-threatening infections.

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32
Q

What usually causes fungal sinusitis?

A
  • rhinocerebral mucormycosis

- aspergillosis

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33
Q

When are most cases of sinusitis present?

A

most cases of sinusitis are present after or in conjunction with viral URI

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34
Q

What are the symptoms of acute rhinosinusitis?

A
  • nasal drainage
  • congestion
  • facial pain and pressure
  • headache
  • thick discolored purulent nasal discharge (not specific to bacterial infection)
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35
Q

What are the other symptoms of acute rhinosinusitis?

A
  • cough
  • sneezing
  • fever
  • tooth pain
  • retroorbital pain radiating to the occiput
  • signs of orbital cellulitis
  • soft tissue edema over the frontal bone (a complication of frontal sinusitis)
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36
Q

Where is the sinus pain and pressure localized?

A

sinus pain and pressure often localizes to the involved sinus (specially when the patient bends over or is supine)

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37
Q

What are the life threatening complications of acute rhinosinusitis?

A
  • meningitis
  • epidural abscess
  • cerebral abscess
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38
Q

How do we diagnose acute rhinosinusitis?

A

illness duration is helpful in the therapeutic decision-making

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39
Q

For how long does the acute bacterial sinusitis last in adults and children?

A

> 10 days in adult and >10-14 days in children + purulent discharge + nasal obstruction + nasal pain

(BUT only 40-50% of patients have true bacterial sinusitis!)

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40
Q

Is the use of CT and RTG recommended in acute rhinosinusitis?

A

The use of CT and RTG is not recommended for acute disease (exception: nosocomial sinusitis)

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41
Q

Immunocompromised with acute rhinosinusitis?

A

An immunocompromised patient should be examined by otolaryngologist

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42
Q

What should be done if we suspect fungal acute sinusitis?

A

if fungal infection is suspected - biopsy specimen should be examined

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43
Q

Nosocomial acute sinusitis suspected -

A

a sinus aspirate or culture and susceptibility testing should be obtained

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44
Q

How do we treat acute rhinosinusitis?

A

most patient improve without antibiotic therapy

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45
Q

How do we treat patients with mild and moderate symptoms of acute rhinosinusitis of short duration?

A

In patients with mild to moderate symptoms of short duration - oral and topical decongestants, nasal saline lavage, at least nasal glucocorticoids

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46
Q

What do we do if there is no improvement after 10 days of symptomatic treatment of acute rhinosinusitis or if the symptoms are severe?

A

If there is no improvement after 10 days of symptomatic treatment or the symptoms are severe - antibiotic therapy should be considered

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47
Q

How should community-aquired sinusitis be treated?

acute rhinosinusitis

A

Community-aquired sinusitis should be treated with the narrowest-spectrum antibiotics active against S.pneumoniae and H.influenzae

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48
Q

What do we do if there is no response to initial therapy of acute rhinosinusitis?

A

No response to initial therapy - consider sinus aspiration or lavage

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49
Q

When should patients be admitted to the hospital?

acute rhinosinusitis

A

Patients with most serious complications should be admitted to the hospital (facial swelling, orbital involvement, intracranial complications, etc)

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50
Q

“Patients with most serious complications should be admitted to the hospital”: what is considered serious complication?
(acute rhinosinusitis)

A
  • facial swelling
  • orbital involvement
  • intracranial complications
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51
Q

How do we treat invasive fungal sinusitis?

A

Invasive fungal sinusitis usually require surgical debridement and treatement with i.v. antifungal agents such as Amphotericin B

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52
Q

Initial therapy:

acute rhinosinusitis

A
  • Amoxicillin, 500 mg PO tid
  • or amoxicillin/clavulanate,
    • 500/125 PO tid
    • or 875/125 mg PO bid – 7-10 days
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53
Q

Penicillin allergy:

acute rhinosinusitis

A
  • Doxycycline, 100 mg PO bid

- or Clindamycin PO, 300 mg tid

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54
Q

If pennicillin-resistant S. pneumoniae etiology is suspected:
(acute rhinosinusitis)

A

amoxicillin/clavulanate 2000/125 mg PO bid

- or moxyfloxacin, 400 mg PO daily

55
Q

Chronic sinusitis

A

Symptoms of sinus inflammation lasting > 12 weeks

56
Q

What are the most common causes of Chronic sinusitis?

A

In most cases bacterial or fungal etiology

57
Q

What are the consequences of chronic sinusitis?

A

Impairment of mucociliary clearance from repeated infections > persistent bacterial infection;
constant nasal congestion and sinus pressure

58
Q

What is helpful in determining of the extent of the chronic sinusitis?

A

CT scan helpful in determining of the extent of the disease

59
Q

Endoscopy is used for:

A

histologic examination and culture

60
Q

Chronic fungal sinusitis:

A

immunocompetent host, usually non invasive e.g. allergic aspergillosis

61
Q

Invasive fungal sinusitis

A

complication of prolonged chronic fungal sinusitis oraz in immunocompromised patients

62
Q

Chronic sinusitis - treatment:

A
  • Repeated culture-guided courses of antibiotic therapy for 3-4 weeks or longer
  • Intranasal glucocorticoids
  • Mechanical irrigation of the sinus with sterile saline solution
  • If no improvement – sinus surgery may be indicated
  • Treatment of chronic fungal sinusitis consists of surgical removal of impacted mucus
  • Recurrence is common…
63
Q

Treatment of chronic fungal sinusitis:

A

Treatment of chronic fungal sinusitis consists of surgical removal of impacted mucus

64
Q

For how long does the treatment of Chronic sinusitis last?

A

3-4 weeks or longer

65
Q

Infections of external ear structures:

A
  • Auricular cellulitis
  • Perichondritis
  • Otitis externa
    • Acute localized otitis externa (furunculosis)
    • Acute diffuse otitis externa/swimmer´s ear
    • Chronic otitis externa
    • Invasive otitis externa: Also known as malignant or necrotizing otitis externa
66
Q

Auricular cellulitis:

A

Infection of the skin overlying the external ear and typically follows minor local trauma

67
Q

Auricular cellulitis - symptoms:

A

Tenderness, erythema, swelling and warmth of external ear

68
Q

Auricular cellulitis - treatment:

A

Treatment consists of warm compresses and oral antibiotics (e.g. cephalexin or dicloxacillin active against S. aureus and Streptococci)

69
Q

Perichondritis:

A

An infection of the perichondrium of the auricular cartilage, usually follows local trauma (e.g. piercings, burns)

70
Q

Perichondritis - symptoms:

A

Symptoms similar to auricular cellulitis, extreme tenderness of the pinna

71
Q

Perichondritis - treatment:

A

antibiotics active against P. aeruginosa (e.g. piperacillin)

72
Q

Otitis externa:

A

Disease involving primarly the auditory meatus

73
Q

What causes Otitis externa?

A

A result of heat and retained moisture, with desquamation and maceration of the epithelium of the outer ear canal

74
Q

What are the classifications of Otitis externa?

A
  • localized
  • diffuse
  • chronic
  • invasive
75
Q

What are the most common pathogens of Otitis externa?

A
  • P. aeruginosa

- S. aureus

76
Q

Furunculosis =

A

Acute localized otitis externa (furunculosis)

77
Q

Acute localized otitis externa (furunculosis) - localization:

A

Develops in the outer third of the ear canal, where hairfollicles are numerous

78
Q

Acute localized otitis externa (furunculosis) - usual pathogen:

A

S. aureus is the usual pathogen

79
Q

Acute localized otitis externa (furunculosis) - treatment:

A
  • antistaphylococcal penicillin (e.g. dicloxacillin or cephalexin)
  • in cases of abscess formation - incision and drainage
80
Q

Acute diffuse otitis externa (Swimmer’s ear) =

A

Swimmer’s ear

81
Q

Acute diffuse otitis externa (Swimmer’s ear)

A

Heat, humidity, loss of protective cerumen

  • > excessive moisture and elevation of the pH in the ear canal
  • > skin maceration and irritation
  • > infection
82
Q

Acute diffuse otitis externa (Swimmer’s ear) - pathogen

A

Predominant pathogen - P. aeruginosa, other gram negative and gram positive organisms also possible

83
Q

Acute diffuse otitis externa (Swimmer’s ear) - symptoms:

A
  • Erythematous, swollen ear canal, white, clumpy discharge

- Itching, pain during manipulation of the pinna or tragus

84
Q

Acute diffuse otitis externa (Swimmer’s ear) - treatment:

A
  • Treatement:
    cleansing the canal, debridement, hypertonic saline , alcohol with acetic acid – used topically, preparations with neomycin and polymyxin +/- glucocorticoids
  • Systemic treatment in immunocompromised patients
85
Q

Chronic otitis externa:

A

Caused by repeated local irritation, often complication of persistent drainage from a chronic middle-ear infection, insertion of cotton swabs.
- Very rare syphilis, tuberculosis, leprosy

86
Q

Chronic otitis externa - symptoms:

A
  • Erythematous, scaling dermatitis

- Pruritus and pain

87
Q

Chronic otitis externa- differential diagnosis:

A

Differential diagnosis: atopic dermatitis, psoriasis, dermatomycosis

88
Q

Chronic otitis externa - treatment:

A

identifying and removing the offending process

89
Q

Invasive otitis externa =

A

malignant or necrotizing otitis externa

90
Q

Invasive otitis externa:

A

An aggressive and potentially life-threatening disease that occurs in elderly diabetic or immunocompromised patients

91
Q

Invasive otitis externa - beginning:

A

Begins in external ear canal as soft tissue infection -> progresses slowly over weeks and months

92
Q

Invasive otitis externa - symptoms:

A
  • Erythematous and swollen ear and external canal, purulent otorrhea, deep-seated otalgia
  • Granulation tissue in the posteroinferior wall of the external canal
93
Q

Invasive otitis externa - progression:

A

Infection can migrate to the base of the skull (osteomyelitis), meninges, brain, facial nerve palsy

94
Q

Invasive otitis externa - pathogen:

A

P.aeruginosa, …., S. aureus, S. epidermidis, Aspergillus, Actinomyces

95
Q

Invasive otitis externa - treatment:

A

surgical cleaning, IV antibiotics for 6-8 weeks (e.g. piperacyllin, cefepime +/- aminoglycosides or fluoroquinolones)
combined with otic glucocorticoids and fluoroquinolones, glycemic control

96
Q

Otitis media:

A

Inflammatory condition of the middle ear that results from dysfunction of the eustachian tube in association with a number of illnesses, including URIs and chronic rhinosinusitis

97
Q

Otitis media - inflammatory response:

A

The inflammatory response in theses conditions leads to the development of a sterile transudate within the middle ear and mastoid cavities

98
Q

Otitis media - cause:

A

Infection may occur if bacteria or viruses from the nasopharynx contaminate the fluid, producing an acute illness

99
Q

Acute otitis media:

A

Typically follows a viral URI (most commonly RSV, influenza virus, rhinovirus and enterovirus), which predispose the patient to bacterial otitis media

100
Q

Acute otitis media - bacterial causes:

A

S. pneumoniae (~35%), H. influenzae, M. catarrhalis, increasing incidence of MRSA infection

101
Q

Acute otitis media - viral:

A

Viruses – alone or with bacteria in 17-40% of cases

102
Q

Acute otitis media - fluid in the middle ear:

A

Fluid in the middle ear demonstrated with otoscopy

103
Q

Acute otitis media - viral causes:

A
  • RSV (most commonly)
  • Influenza virus
  • Rhinovirus
  • Enterovirus
104
Q

Acute otitis media - TM:

A

Movement of tympanic membrane (TM) is impaired when fluid is present

105
Q

Acute otitis media - signs and symptoms:

A
  • local or systemic
  • otalgia
  • otorhhea
  • diminished hearing
  • fever
  • veritgo
  • nystagmus
  • tinnitus
106
Q

Acute otitis media- treatment:

A
  • Initial observation, administering anti-inflammatory agents for pain management, reserving antibiotics for high risk patients or complicated disease
  • Patient’s condition does not improve after 48-72h – antibiotic therapy
  • A switch in regimen recommended if there is no clinical improvement by the third day of therapy
107
Q

Acute otitis media - Immediate treatment with antibiotics is indicated for:

A
  • patients <6 months old
  • 6 months-2 years old with middle-ear effusion
  • > 2 years with bilateral disease
  • patients with TM perforation
  • immunocompromised, with severe symptoms including fever ≥ 39oC
108
Q

Chronic otitis media:

A

Persistent or reccurent purulent otorrhea in the setting of TM perforation

109
Q

Chronic otitis media - hearing:

A

Some degree of conductive hearing loss

110
Q

Chronic otitis media - Inactive disease:

A

Inactive disease - central perforation of the TM, which allows drainage of purulent fluid from the middle ear

111
Q

Chronic otitis media - Peripheral perforation:

A

Peripheral perforation - squamous epithelium from the auditory canal may invade the middle ear trough the perforation forming cholesteatoma at the site of invasion

112
Q

Chronic otitis media - treatment:

A
  • mastoidectomy
  • myringoplasty
  • tympanoplasty (in 80% successful)
113
Q

Mastoiditis:

A

Because of anatomic connection, a process of fluid collection and infection is usually the same in the mastoid as in the middle ear

114
Q

Mastoiditis what is the reason that the incidence of acute mastoiditis has declined?

A

Early and frequent treatment of acute otitis media is probably the reason that the incidence of acute mastoiditis has declined

115
Q

Mastoiditis - What happens?

A

Purulent exudate collects in the mastoid air cells -> erosion of the surrounding bone - > abscess-like cavities

116
Q

Mastoiditis - Symptoms:

A
  • pain
  • erythema
  • swelling of the mastoid process
  • displacement of pinna + symptoms of acute otitis media
117
Q

Mastoiditis - Serious complications (rarely):

A

subperiostal abscess of temporal bone, deep neck abscess, septic thrombosis of lateral sinus

118
Q

Mastoiditis - Etiology:

A
  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis
  • S. aureus
  • P. aeruginosa
119
Q

Mastoiditis - Treatment:

A

most patients can be treated conservatively with IV antibiotics, some times surgical treatment

120
Q

Acute pharyngitis - most common causes:

A

A majority of cases caused by typical respiratory viruses

(Rhinoviruses ~20%, Coronoviruses ~5%, Influenza- Parainfluenza-, Adenoviruses, HSV1/2, coxackievirus A, CMV, EBV, acute HIV infection…)

121
Q

Acute pharyngitis - % of pts with no identified cause:

A

30% of pts have no identified cause

122
Q

Acute bacterial pharyngitis typically caused by:

A
  • Acute bacterial pharyngitis typically caused by S.pyogenes - in 5-15% of adult patients;
  • Streptococci of groups C and G - minority of cases
123
Q

Acute pharyngitis - Fusobacterium necrophorum:

A

Fusobacterium necrophorum - increasing incidence, acute pharyngitis may precede a life threatening Lemierre’s disease

124
Q

Acute pharyngitis - The remaining bacterial causes:

A
  • N. gonorhoeae
  • Corynebacterium diphteriae
  • Corynebacterium ulcerans
  • Yersinia enterocolitica
  • Treponema pallidum
125
Q

Acute pharyngitis:

A

Anaerobic bacteria may cause Vincent’s angina -> peritonsillar and retropharyngeal abscesses

126
Q

Acute pharyngitis - Signs and symptoms:

Clinical manifestations:

A

Signs and symptoms are not reliable predictors of the etiologic agent

127
Q

Acute pharyngitis - Signs and symptoms:

Clinical manifestations:

A

Disease caused by adenovirus or HSV may be difficult to differentiate from streptococcal pharyngitis - in all pharyngeal exudate may be present

128
Q

Acute pharyngitis - Adenoviral pharyngitis:

Clinical manifestations:

A

Adenoviral pharyngitis - in ~50% of cases conjunctivitis

129
Q

Acute pharyngitis - HSV:

Clinical manifestations:

A

HSV - presence of vesicles and shallow ulcers on the palate

130
Q

Acute pharyngitis - Coxackie:

Clinical manifestations:

A

Coxackie - small vesicles that develop on the soft palate and uvula and after rupturing form shallow white ulcers

131
Q

Acute pharyngitis - Exudative pharyngitis:

Clinical manifestations:

A

Acute exudative pharyngitis seen in EBV or CMV mononucleosis

132
Q

What is the primary goal of pharyngitis diagnosis?

A

separating acute pharyngitis from pharyngitis of other ethologies

133
Q

What is the most appropriate test for pharyngitis diagnosis?

A

throat swab culture is generally regarded as the most appropriate but cannot distinguish between infection and colonisation and requires 24-48h to yield result

Infectious Diseases (4th year) (19 decks)

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