Download IDSA practice guidelines for the diagnosis and management of

Case discussion
R1 游俊豪
• 12 y/o male
• CC: Intermittent fever for 4 days
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Denied any previous systemic disease
GA 31wk, BBW: 1900gm, twin
BW: 49.5kg (>90th percentile)
Development: normal
Present illness
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Fever up to 39.5’ for 4 days
Sore throat for 3 days
bilateral red, and itching eyes
Slight cough with less amount of sputum
Loose stool passage for 2 times per day
Headache at frontal area
no rhinorrhea, SOB, chest pain
no N/V, no abdominal pain
activity & appetite: fair
No travel hx or animal contact hx
PE
• Conjunctiva: injected, with discharge
• Sclera: not icteric
• Throat: injective, no petechia
enlarged tonsil, no exudate
• Neck: no lymphadenopathy
• Breathing sound: bil clear, no wheezing,
no crackles,
• Heart: RHB, no audible murmur
• Abdomen: soft and flat
• Skin: no rash
• Diagnosis: r/o Pharyngoconjunctival fever
• Orders: 1. symptomatic treatment
2. throat swab for GAS culture
and rapid test
3. MBD and OPD f/u
Lab
• Throat swab for GAS: negative
• Throat swab for aerobic culture: no growth
Discussion
• Pharyngoconjunctival Fever
--an acute and highly infectious illness characterized by
fever, pharyngitis, acute follicular conjunctivitis, and
regional lymphoid hyperplasia with tender, enlarged
preauricular adenopathy.
• Who is at risk for adenovirus infection ?
 Children younger than 14 years
 People in daycare center, military training camps, and
swimming clubs.
• Pharyngitis alone occurs in young children,
particularly those younger than 3 years, and
may mimic streptococcal infection.
• PC fever occurs more often in outbreaks
involving older children.
Hx and PE
• Patients may give a history of recent exposure to
an individual with red eye at home, school, or
work
• PCF is characterized by its associated systemic
manifestations: sudden or gradual onset of fever
+ myalgia, malaise, and GI disturbances
• The pharyngitis may be mild or quite painful.
• The conjunctivitis range from slight itching and
burning to marked irritation and tearing.
• The conjunctivitis most frequently is bilateral,
with one eye having onset 1-3 days prior to the
second eye.
Diagnosis
• Diagnosis of PCF generally is made based on
clinical presentation alone.
• A variety of methods can be used to detect
adenovirus infection, depending on the site and
severity of infection.
• Isolation of adenovirus from the throat of a
patient with pharyngitis is usually diagnostic if
laboratory findings eliminate other common
cause of pharyngitis, such as Steptococcus
pyogens.
IDSA practice guidelines for the diagnosis and
management of group A streptococcal pharyngitis
• Although the group A streptococcus is the most
common bacterial cause of acute pharyngitis,
only a small percentage of patients with this
condition are infected by group A streptococci.
• group A streptococcal pharyngitis is the only
commonly occurring form of acute pharyngitis for
which antibiotic therapy is definitely indicated.
• for a patient with acute pharyngitis, the clinical
decision that usually needs to be made is
whether the pharyngitis is attributable to group A
streptococci
• Establish the diagnosis of "strep throat→ A positive
result of throat culture or rapid antigen detection testing
(RADT) + signs and symptoms of acute pharyngitis
• RADT: 90~95% specitivity
60~95% sensitivity
• if (+) → establishing the diagnosis
• if (-) → does not rule out GAS infection，should be
confirmed by throat culture for a child or adolescent
• Because of the epidemiological features of acute
pharyngitis in adults (eg, low incidence of streptococcal
infection and extremely low risk of rheumatic fever),
diagnosis of this infection in adults on the basis of the
results of an RADT is acceptable.
IDSA practice guidelines for the diagnosis and
management of group A streptococcal pharyngitis
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The algorithm applies to uncomplicated cases of acute pharyngitis. Additional
diagnostic and therapeutic measures may be necessary for patients with suppurative
complications (eg, peritonsillar abscess or cervical lymphadenitis) or infection with
uncommon pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae,
Neisseria gonorrhoeae) is suspected.
* See the discussion in Diagnosis of Group A Streptococcal Pharyngitis. Clin Infect Dis 2002; 35:113.
Who should be tested for group A betahemolytic streptococcal pharyngitis?
• Testing usually need not be done for patients
with acute pharyngitis that has clinical and
epidemiological features not suggestive of a
group A streptococcal etiology.
• Some clinical scoring systems are helpful in
identifying patients who are at such low risk of
streptococcal infection that performance of a
throat culture or an RADT is usually
unnecessary.
Epidemiology
• A history of close contact with a welldocumented case of streptococcal
pharyngitis
• an awareness of a high prevalence of
group A beta-hemolytic streptococcal
infections in the community
• GAS cause 15~30 % of cases of acute
pharyngitis in pediatric patients but only 5
~10 % in adults
Signs and symptoms of pharyngitis were
derived from the practice guidelines of the
Infectious Diseases Society of America
• Suggestive of virus →conjunctivitis, coryza,
cough, diarrhea, and viral-like exanthema
• Suggestive of bacteria →fever >38.5°C,
tender cervical node, headache, petechia
on the palate, abdominal pain, and sudden
onset (<12 hours), aged 5-15y/o
clinical scoring systems
Pharyngitis in Low-Resources
Settings
the decision rule to apply according to the score
• A cutoff of 8 was chosen as having the optimal
risk/benefit ratio.
• A clinical score 8 suggests a symptomatic
treatment with an 84% specificity for non-GAS
pharyngitis.
• If bacteriologic diagnosis is unavailable, the
application of that recommendation would have
reduced the antibiotic prescription by 41%.
• If limited bacteriologic diagnosis is available, the
application of this recommendation would have
reduced the antibiotic prescription by 55%.
Reference
• Medical microbiology
• E medicine, Pharyngoconjunctival Fever , Author: Ingrid
U Scott, MD, MPH, Professor, Department of
Ophthalmology and Health Evaluation Sciences, Penn
State College of Medicine
• IDSA practice guidelines for the diagnosis and
management of group A streptococcal pharyngitis
• Principles and Practice of Pediatric Infectious
Diseases, 2nd ed., Copyright © 2003 Churchill
Livingstone, An Imprint of Elsevier
• Diagnosis and Treatment of Pharyngitis in Children
Michael A. Gerber, MD
• Pediatrics: Pharyngitis in Low-Resources Settings
• McIsaac WJ, White D, Tannenbaum D, Low DE. A
clinical score to reduce unnecessary antibiotic use in
patients with sore throat. CMAJ. 1998;158 :75 –83