W31 Sore throat and fungal infection of the mouth Flashcards
What are the symptoms of a sore throat?
- a painful throat, especially when swallowing
- a dry, scratchy throat
- redness in the back of the mouth
- bad breath
- a mild cough
- swollen neck glands
Children also present with fever and lethargy
What are the causes of a sore throat? ( 4 conditions)
- laryngitis
- tonsillitis
- strep throat (a bacterial pharyngitis)
- glandular fever
- others?
Pharyngitis - inflammation of the pharyngeal mucosa
What is acute pharyngitis characterised? (3)
What is it caused by? (3)
- Acute pharyngitis is characterised by the rapid onset of sore throat and pharyngeal inflammation (with or without exudate).
-the absence of cough, nasal congestion and discharge suggests a bacterial aetiology
Aetiology of acute pharyngitis:
* Viral pathogens (almost always): e.g., rhinovirus
* Bacterial pathogens: e.g., group A Streptococcus (GAS)
* Fungal pathogens: e.g., Candida albicans
bacterial-exudate
viral- no exudate
Tonsillitis - inflammation of the tonsillar tissues
What are the signs and symptoms?
- Self-limiting condition
- Common cause is viral
- Bacterial cause is suspected if lasting ˃ 3 days
- Swollen/ erythematous tonsils
- Exudate on tonsils
- Cervical lymphadenopathy
- Stertor (noisy breathing )
- Pyrexia
- Sore throat
- Odynophagia & dysphagia
- Cough
Diagnosis of Sore throat:
What should be taken from patient?
What are the diagnositic tools? (2)
History taking (e.g., other symptoms, previous episode, other medical condition,other medications)
Diagnostic tools:
* FeverPain criteria or Centor criteria
* Rapid antigen detection tests (RADT) – allow immediate point of care assessment of GAS pharyngitis
Differential diagnosis of sore throat:
- Hand, foot, and mouth disease
- Epiglottis
- COVID-19
- HIV
- Gonorrhoea
- Measles
- Leukaemia
- Oropharyngeal cancer
- Lemierre syndrome
- Kawasaki disease
What are examples of red flag symptoms of sore throat?
Difficulty breathing
Difficulty swallowing
Dehydration
Excessive drooling (in young children)
Immunosuppressant use
Rash
Patient severely unwell
Blood in saliva or phlegm
FeverPAIN criteria
- Each criteria score 1 point (max score 5)
- Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.
- 0 or 1 score – 13 to 18% likelihood of isolating GAS
- 2 or 3 score – 34 to 40% likelihood of isolating GAS
- 4 or 5 score – 62 to 65% likelihood of isolating GAS
Criteria:
* Fever (during previous 24 hours)
* Purulence (pus on tonsils)
* Attend rapidly within 3 days after onset of symptoms
* Severely inflamed tonsils
* No cough or coryza (inflammation of mucus membranes in the nose)
What are the Centor criteria? (4)
- Each criteria score 1 point (max score of 4).
- A score of 0, 1 or 2 – associated with a 3 to 17% likelihood of isolating GAS
- A score of 3 or 4 – associated with a 32 to 56% likelihood of isolating GAS
(group a streptococcus)
Criteria:
* Tonsililar exudate
* Tendor anterior cervical lymphadenopathy or lymphadenitis (tender or swollen cervical lymph nodes)
* History of fever (Temp-over 38°C)
* Absence of cough
Sore throat- what treatment is used?
Self care? (3)
Abx given?
Corticosteroids?
Self-care
* Oral analgesia: e.g., paracetamol or ibuprofen
* Medicated lozenges – help to reduce pain
* Other interventions: e.g., mouth wash
- Antibiotics (based on FeverPAIN or Centor score)
- Corticosteroids is NOT recommended for the
treatment of acute pharyngitis (lack of evidence)
Sore throat- treatment (2)
- Patient education – self-limiting condition (usual course can last around 1 week)
- Managing symptoms (self-care)
- Safety netting – reassessment if symptoms worsen
-No improvement? Alternative diagnosis (e.g., Scarlet fever or glandular fever)?
-Any symptoms or sign suggesting a more serious illness (e.g., difficulties in swallowing or
breathing, throat swelling)
-Previous antibiotic use – resistant organism? - For patient with severe recurrent tonsillitis – tonsillectomy
Antibiotic therapy for acute sore throat
1st, 2nd, 3rd line??
- Antibiotics targeted against the most common pathogen – Streptococcus pyogenes
- Phenoxymethylpenicillin – first line
- Clarithromycin – penicillin allergy
- Erythromycin – penicillin allergy in pregnancy
- Refer to acute sore throat CKS guideline -Prescribing information
What are the complications of streptococcal pharyngitis/tonsillitis?
- Scarlet fever
- Suppurative complications
-Otitis media (most common).
-Acute sinusitis — rare
-Peri-tonsillar abscess (quinsy) - Non-suppurative complications include acute rheumatic fever, acute glomerulonephritis and reactive arthritis, although these are rare in
developed countries.
Fungal infection of the mouth:
Caused by?
- Usually caused by Candida spp.
- Management depends on the types of oropharyngeal candidiasis
- Pseudomembranous candidiasis (Thrush) – Antifungal
- Acute erythematous candidiasis – Antifungal
- Denture stomatitis – Denture cleanse with disinfectant solution, brushing, Miconazole?
What are the symptoms of Pseudomembranous candidiasis (thrush)? (3)
- An acute infection
Signs & Symptoms
* Patches of curd-like, white or yellowish plaques
* Burning & itching sensation (minimal)
* Dysphagia and chest pain (chronic form)
What are the risk factors in developing oral thrush?
- Extremes of age
- Immunocompromise or systemic immunosuppression
-Patients with serious systemic disease associated with reduced immunity (e.g.,
leukaemia, other malignancies, and HIV infection)
-Patient receiving chemotherapy and radiotherapy - Recent or concurrent use of drugs that promote candida growth
-Patient receiving ICS, chemotherapy, broad-spectrum antibiotics - Diabetes mellitus
- Dental prostheses and poor dental hygiene
- Smoking
- Local trauma
- Poor diet and nutritional deficiencies
- Impaired salivary function
Management of oral candidiasis in primary care – adult (non-immuonocompromised)
Oral candidiasis presentation, Check risk factor: = Risk factor (DM, haematinic deficiencies)
1. Manage risk factors
2. Refer
=No risk factor
1. Prescribe antifungal
* Localised and mild infection
= Topical antifungal for 14 days -Miconazole oral gel- 1st line
Lifestyle advice
* Extensive and severe infection
=Systemic antifungal for 14 days- Oral fluconazole
Lifestyle advixe
Review and extend Tx for 7 days
Management of oral candidiasis in primary care – children (non-immuonocompromised)
Oral candidiasis presentation, Check risk factor: = Risk factor (DM, haematinic deficiencies)
1. Manage risk factors
2. Refer to paediatrician
=No risk factor
1. Prescribe topical antifungal
Miconazole oral gel for 14 days ( children > 4 months)- 1st line
OR
** Oral Nystatin suspension (if miconazole is unsuitable)
Lifestyle advice
Non-pharmacologic management of oral thrush?
- Good dental hygiene
- If using ICS, advice on good inhaler technique, rinsing mouth with water, use
a spacer device - Smoking cessation
- Denture cleanse and removal for at least 6 hours per day
- Brush the mucosal surface with soft brush
- Advice on manging risk factors (e.g., DM)
Oral thrush Do’s and Don’ts
DO:
- take care of your teeth: brush twice a day, clean your dentures
- brush your gums and tongue with a soft toothbrush if you dont have teeth
- sterilise dummies regularly
- sterilise bottles after each use
- rinse your mouth after eating or taking medicine
- go to regular checkups if you have a long-term condition like diabetes (DM)
DON’T:
- wear your dentures at night
- keep wearing dentures if they dont fit properly-see dentist
- smoke
Which ONE of the following is NOT a symptoms of strep throat?
A. Sudden onset sore throat
B. Odynophagia (painful swallowing)
C. Nasal congestion, nasal discharge and cough
D. White or yellow patches seen on the tonsils and throat (tonsillar exudate)
=C (this would be a viral infection)
- absence of these signifies acute pharyngitis
Which ONE of the following is a rare but serious complication of strep throat?
A. Stroke
B. Rheumatic fever
C. Shingles
D. Rickets
=B
