Download What are the etiologic agents of Tonsillopharyngitis in children?

Cases for the Pediatric
IV Module
CASE I
“Kizzin Cuzzins”
Topics for Case 1
Grp A B-hemolytic Streptococcus
C. diphtheriae
Grp C B-hemolytic Streptococcus
N. gonorrheae
S. aureus
Candida Albicans
Adenovirus
Epstein Barr virus
Coxsackie virus (Herpangina)
Herpes simplex virus
Adenovirus
Parainfluenza virus
Influenza virus
Mumps
1.
2.
3.
4.
5.
6.
Questions/Tasks
How would you approach the problem of sore throat?
What are the etiologic agents of Tonsillopharyngitis in
children?
What is/are the distinguishing feature/s of
Tonsillopharyngeal diphtheria?
What differentiates the ‘bull-neck” appearance of
Diphtheria from Mumps?
What laboratory tests/procedures is/are indicated to
confirm the diagnosis of Diphtheria?
What complications of Diphtheria can be anticipated?
7. Give the curative and preventive principles of therapy
for diphtheria
8. What is the drug of choice and acceptable alternative
therapies for Streptococcal tonsillopharyngitis?
9. What is the rationale and goals of treatment of Grp A
B-hemolytic Streptococcal tonsillopharyngitis?
10. What are the indications for removal of the tonsils
and adenoids?
Case 1 – “Kizzin Cuzzins”
• Em-em, 9 years old; female
• Chief complaint: high fever and sore
throat with difficulty of swallowing
accompanied by vomiting and chilly
sensation.
• Mother Had “colds” characterized by
watery nasal discharge, sneezing and an
itchy throat 3 days earlier
• PE: Temp. 39.40C; CR-120/min.; RR33/min.; appeared acutely ill and toxic.
Case 1 – “Kizzin Cuzzins
• Posterior pharynx, palatine tonsils and
uvula acutely inflamed, bright red and
edematous; tonsils markedly enlarged
(“kissing”) with several discrete white to
gray exudates noted over each tonsillar
area.
• Right tympanic membrane was dull and
slightly edematous
Question 1:
How would you approach
the problem of sore
throat?
Approach
• The best presenting manifestation for this
patient is sore throat.
• “Sore throat” is one of the most common
complaints of children seen for medical
treatment.
• Infection may involve the pharynx diffusely
(acute pharyngitis) or localized predominantly to
the palatine tonsils (acute tonsillitis).
• The diagnosis is made by carefully visualizing the
throat. Erythema, exudates and swollen tonsils
are all signs of infection.
• The clinician faces the basic problem of
differentiating self-limiting viral infections
from bacterial infections that require
antibiotic tx
Question 2:
What are the etiologic
agents of
Tonsillopharyngitis in
children?
Etiologic agents
• Eichenwald estimates that 80 –90% of ATP’s
are due to viral agents. Adenovirus,
Parainfluenzae and influenzae etc. have
implicated in infections of the pharynx and
tonsils.
• Enteroviruses, EBV, Herpes simplex virus may also present
as oral lesions
• GABHS is the most common cause of bacterial
infection in the pharynx
– Others: Group C;S. aureus, Gram (-) organisms, M.
pneumoniae and rarely N. gonorrhea and
Corynebacterium diphtheriae. ( see p.1396 NELSON)
• Candida occur in the immunocompromised or
those chronically treated with antibiotics
Common Etiologic Agents for
Acute Pharyngitis
Types of Pharyngeal Lesions:
(in diminishing frequency)
• Erythematous – S. pyogenes, Adenovirus,
C.pneumoniae
• Follicular – Adenovirus, S. pyogenes (to a much lesser
degree)
• Exudative – C. diphtheriae, EBV, S. pyogenes
• Ulcerative – Herpes simplex, Enterovirus
• Petechial – S. pyogenes, EBV
Modified from:
Cherry JD, Textbook of Pediatric Infectious Disease
4th edition
Epstein-Barr virus
infection
Infectious mononucleosis
• The tonsils are swollen and
covered with uniform white
exudates. Uvula looks
swollen and the patient’s
speech is nasal
• The typical exudate are
patches forming thick
plaques of opaque white
membrane
Anginose variety of
Infectious Mononucleosis
Epstein-Barr virus
infection
Infectious Mononucleosis
• Moderate leukocytosis
develops between the 1st and
2nd week – the result of an
absolute increase in
circulating lymphocytes many
of which are abnormal
• A large number of atypical
mononuclear cells in
peripheral blood is one of the
characteristics of the
disease
Atypical lymphocytes
Herpangina (Enterovirus)
Herpangina:
• Caused by type A
coxsackievirus
• Characterized by an
acute onset with high
fever, sore throat and
dysphagia.
• Throat is inflamed and
small discrete vesicles
surrounded by a band of
erythema may be seen
scattered over the
palate, fauces and
pharynx
Herpes simplex Infection
Herpetic stomatitis:
• Presents as vesicular
(ulcerative) eruptions
but tend to affect the
anterior half of the
buccal cavity whereas
herpangina is confined
to the posterior
Herpetic gingivostomatitis
Herpes simplex Infection
Herpetic gingivostomatitis in adult
Thrush
Oral Candidiasis:
• May occur in infants as a
result of cross-infection
from the mother or
other infants esp. in
bottle-fed babies
• In adults, infection is
usually endogenous &
found in dehydrated or
debilitated patients or
when the bacterial flora
is disturbed by antibiotic
therapy
Viral vs. Bacterial tonsillopharyngitis
Features
Time course of onset
Presenting Sx:
Gen. Toxicity/malaise
Abdominal pain
Vomiting
Headache
Fever
Respiratory tract:
Cough
Hoarseness
Nasal congestion
Conjunctivitis
Acute Streptococcal
Non-GBS (Viral)
Sudden
Gradual
Moderate to severe
Common
Common
Common
Moderate to high
Mild to moderate
Rare
Rare
Rare
Low to mod.high
Rare
Rare
Rare
Rare
Common
Common
Common
Common
Ambulatory Pediatrics, Green and Haggerty
Viral vs. Bacterial tonsillopharyngitis
Features
Pharynx:
• Sore throat
• Tonsillar
erythema
• Exudate
• Petechial on soft
palate
Acute Streptococcal
Non-GBS (Viral)
Very common
Moderate to extensive
Common
Minimal to moderate
Small to extensive (if
extensive rule out
Diphtheria)
Common
None to small (except
EBV - may have
extensive exudates)
Rare
Ant.cervical nodes:
• Enlarged
Moderate to extensive Minimal to moderate
• Tender -palpation Moderate to severe
Minimal to moderate
Age
Generally > 3 yrs.
Any age
Ambulatory Pediatrics, Green and Haggerty
Streptococcal Tonsillopharyngitis
Exudative Tonsillitis
Cervical lymphadenitis
Question 3:
What is/are the
distinguishing feature/s
of Tonsillopharyngeal
Diphtheria?
Tonsillopharyngeal
Diphtheria
• The membrane of
diphtheria tends to be
darker, grayer, more
fibrous and adherent
than in other
conditions .
• When forcibly
removed, bleeding is
likely to occur
• Knowledge of the
child’s immune status
is helpful in
differentiating
Tonsillopharyngeal Diphtheria
Diphtheria Epidemiology
• In many developing tropical countries
where immunization is not routinely
performed, the disease is still common and
results in considerable morbidity and a
significant mortality.
• The organism produces an exotoxin which
is species specific however only strains
infected with a bacteriophage carrying tox
gene are toxigenic
• 88 cases (National Epidemiology Center,
DOH 2003)
Question 4:
What differentiates the
“bull-neck” appearance of
Diphtheria from Mumps?
Diphtheritic cervical
adenitis vs Mumps
• Diphtheria -the
neck is swollen due
to cervical adenitis
and periglandular
edema. At this
time, patient is
very ill, toxic,
lethargic, drowsy
but often afebrile
Mumps
• Rapid onset of parotitis appearing
2-3 wks. following contact.
• Prodromal sx of malaise, myalgia,
headache and pain over parotid
glands.
• Constitutional sx become more
intense in next 1-3 days and
parotid swelling displaces the
earlobe outwards and upwards.
• Pain is aggravated by chewing and
tasting sour fluids
• Orifices of Stensen’s & Wharton’s
ducts are erythematous and
pouting
Question 5:
What laboratory
tests/procedures is/are
indicated to confirm the
diagnosis of Diphtheria?
Diphtheria
• The diagnosis of diphtheria must be made
early and on clinical grounds so that
treatment can be given early and progress
of the disease halted.
• If clinical index of suspicion is high,
treatment must be initiated even before
laboratory confirmation
• Confirmation -positive identification of
C.diphtheriae on selective media
• Schick test is useful for determining
immune status to diphtheria
Question 6:
What complications of
Diphtheria can be
anticipated?
Diphtheria
• Complications:
– Myocarditis
– Neuritis
– Glomerulonephritis
• 2/3 of patients develop myocarditis but in
only 10-25% is this clinically important.
Occurs between D10 and D20
• Neuritis affects 75% of patients with
severe disease.
– Affects cranial & peripheral nerves: palate (3
wks); oculomotor (4 wks); respiratory (7 wks)
and peripheral nerves (10 wks)
7. Give the Curative and
Preventive principles of
therapy of Diphtheria
Question 8:
What is the rationale
and goals of treatment
of Group A B-hemolytic
Streptococcal
tonsillopharyngitis?
Rationale and goals of Tx
1.
2.
3.
4.
Prevent rheumatic fever
Prevent suppurative complications
Abatement of clinical symptoms
Reduce transmission of group A
streptococcus
5. Minimize adverse effects of
inappropriate antibiotic therapy
Recommendations of Infectious Diseases
Society of America, CID 25:574,1997
Question 9:
What is the Drug of
choice and acceptable
alternative therapies for
Streptococcal
tonsillopharyngitis
DOC for Streptococcal
tonsillopharyngitis
• Except in penicillin-allergic patients,
Penicillin V is the drug of choice
(there has been no documented
reports of resistance)
• Erythromycin most widely
recommended for penicillin-allergic
patients
Question 10:
What are the indications
for removing the tonsils
and adenoids?
Tonsillectomy and Adenoidectomy
DEFINITE:
• Obstructive tonsils/adenoids causing
obstructive apnea or cor pulmonale
• Malignancy
• Persistent or recurrent tonsillar
hemorrhage
RELATIVE:
• Peritonsillar abscess
• Recurrent documented tonsillitis
• Chronic otitis media with effusion
Bluestone CD: Current indications for Tonsillectomy & Adenoidectomy
Ann. Otol.Rhinol. Laryngol, 101:58-64,1992
Key Learning Points for
Sore throat
• Not all ‘streptococcal-looking” pharyngitis
is due to streptococcus
• Streptococcal sore throat in infants is
rare. Adenovirus is a more common etiology
of pharyngitis of this age
• Treatment of Strep throat helps prevent
rheumatic fever and may speed up recovery
from pharyngitis
• Streptococcal tonsillopharyngitis relapses
should be treated with alternatives to
penicillin if the patient did have good
compliance with the initial PCN course
CASE 1
“Kizzin Cuzzins”