Download Acute_Pharyngitis

ACUTE PHARYNGITIS
NURS 870
OBJECTIVES
Students will be able to:
1. Identify the most common causes of pharyngitis in the
outpatient setting.
2. Evaluate for possible Group A strep infection
3. Identify possible complications of untreated Group A Strep
4. Identify & treat other common causes of acute pharyngitis
COMMON CAUSES
• Bacteria
• Group A Strep (GAS)
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aka: group A beta-hemolytic strep (GABHS)
Of the Streptococcus pyogenes [family of gram+ bacteria]
Can be part of the normal flora
Can also cause cellulitis/skin infections
• Pertussis & …many others
• Viruses
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Many URI viruses
Epstein Barr Virus
HSV (primary infection)
Coxsackie A virus (herpangina)
HIV (acute infection)
• Fungi (candida)
• Other oral lesions
WHAT NOT TO MISS
• Group A Strep due to its association with:
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Peritonsillar abscess
Scarlet fever
Acute rheumatic fever
Acute glomerulonephritis
GROUP A STREP PHARYNGITIS
• Typical CC/HPI findings:
• Sudden onset sore throat
• Fever > 101
• Age 5-15 (though 10% of adults cultured are + for Strep A)
• Patients should typically NOT have URI symptoms:
• Runny nose
• Cough
GROUP A STREP PHARYNGITIS
Typical findings on History & PE:
• Sudden onset of sore throat
• Age 5–15 years
• Fever
• Headache
• Nausea, vomiting, abdominal pain
• Tonsillopharyngeal inflammation
• Patchy tonsillopharyngeal exudates
• Palatal petechiae
• Anterior cervical adenitis (tender nodes)
• Winter and early spring presentation
• History of exposure to strep pharyngitis
• Scarlatiniform rash
IDSA Pharyngitis Guidelines 2012
GROUP A STREP: PE
Tonsillar exudate 1
Retrieved from: http://www.healthline.com/health/sore-throat#Overview1
GROUP A STREP: PE
Tonsillar exudate 2
Retrieved from: http://www.healthline.com/health/sore-throat#Overview1
GROUP A STREP: PE
Palatal petechiae
Retrieved from: http://www.healthline.com/health/sore-throat#Overview1
GROUP A STREP: PE
Anterior cervical adenopathy
Retrieved from: http://www.anatomy.yalemedicine.org/VisibleHumanLessonPlans/PCC1.VitalSigns.htm
GROUP A STREP: PE
Click here for scarlet fever rash images:
http://www.atsu.edu/faculty/chamberlain/Scarletfev
er.htm
GROUP A STREP: DX
Click here for MD Calc Centor Score:
http://www.mdcalc.com/modified-centor-score-for-streppharyngitis/
5 Criteria:
Tonsillar exudate
Tender/swollen anterior cervical nodes
Fever > 100.4
Absence of cough
Age: Age 3-14 +1
Age 15-45 +0
Age >45 -1
Centor Criteria
GROUP A STREP: DX
Clinical Decision based on Centor Score:
Score 4-5:
Score 2-3:
Score 0-1:
Centor Criteria
Treat with antibiotics
Rapid strep antigen test
If positive: treat with antibiotics
If negative: throat culture
Symptomatic pharyngitis treatment
GROUP A STREP: RX
Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis:
2012 Update by the Infectious Diseases Society of America
Table 2. Antibiotic Regimens Recommended for Group A Streptococcal Pharyngitis
Drug, Route
Dose or Dosage
Duration or Quantity
Rec. Strength
For individuals without penicillin allergy
Penicillin V, oral
Children: 250 mg
adolescents/adults:
BID or TID x 10 d
250 QID or 500 mg BID x 10 d
Strong, high
Amoxicillin, oral
50 mg/kg
alt: 25 mg/kg
once daily (max = 1000 mg) x 10 d
BID x 10 d (max = 500 mg) x10 d
Strong, high
1 dose
Strong, high
Benzathine penicillin G, IM <27 kg: 600 000 U;
≥27 kg: 1 200 000 U
For individuals with penicillin allergy
Cephalexin,b oral
Cefadroxil,b oral
Clindamycin, oral
20 mg/kg/dose
30 mg/kg
7 mg/kg/dose
BID (max = 500 mg/dose) x 10 d
once daily (max = 1 g) x 10 d
TID (max = 300 mg/dose) x 10 d
Strong, high
Strong, high
Strong, moderate
Azithromycin,c oral
Clarithromycin,c oral
12 mg/kg
7.5 mg/kg/dose
once daily (max = 500 mg) x 5 d
BID (max = 250 mg/dose) x 10 d
Strong, mod
Strong, moderate
b
c
Avoid in individuals with immediate type hypersensitivity to penicillin.
Resistance of GAS to these agents is well-known and varies geographically and temporally.
GROUP A STREP: COMPLICATIONS
Early Left Peritonsillar Abscess
Swelling and erythema above
the left tonsil. The uvula is
slightly swollen as well.
Compare to the right
peritonsillar area which looks
normal.
Retrieved from: http://www.ghorayeb.com/PeritonsillarAbscess.html
GROUP A STREP: COMPLICATIONS
Early Left Peritonsillar
Abscess
Swelling, redness and
protrusion of the left tonsil
which is covered with
white exudate. The uvula
is slightly displaced to the
opposite side
Retrieved from: http://www.ghorayeb.com/PeritonsillarAbscess.html
GROUP A STREP: COMPLICATIONS
Rheumatic Fever
Occurs ~ 2-4 weeks after untreated GAS
Most common in ages 5-15
May damage:
joints
heart
- migratory polyarthritis
- initially carditis
- long term: CHF, valve stenosis, dysrhythmias
skin
- nodules resembling those of RA
neuro - Sydenham’s chorea
https://www.youtube.com/watch?v=V74h6eFpk-8
GROUP A STREP: COMPLICATIONS
Acute Glomerulonephritis
Occurs 1-2 weeks after untreated GAS throat
or 2-4 weeks after a skin infection (impetigo)
Most common in ages 6-10
Symptoms:
decreased urine output
rust-colored urine (or gross hematuria)
generalized edema
Rx: antibiotics, BP meds, diuretics as indicated
Referral to nephrology
Resolves over weeks to months
PERTUSSIS
 Caused by Bordatella pertussis – gram negative coccobaccli
 Highly contagious. Affects all ages, but 70% of cases in
children
 Most deaths occur in infants < 6 months
 Incidence is on the rise due to decreased immunization rates
 No life-long immunity but subsequent infections (or those which
occur in vaccinated individuals) may be mild and
undiagnosed
PERTUSSIS
3 stages of symptoms following 7-14 day incubation period:
 Catarrhal stage ~ 2 weeks
• Typical URI symptoms: sneezing, watery eyes, hacking
nocturnal cough
• Difficult to differentiate from influenza or bronchitis
 Paroxysmal ~ weeks 2-4 of illness
• Increase in severity and frequency of cough
• Paroxysms of forceful coughing followed by a “whoop”
• Post-tussive vomiting
• Cough samples:
[http://www.merckmanuals.com/professional/infectious_diseases/gramnegative_bacilli/pertussis.html?qt=pertussis&alt=sh]
 Convalescent ~ weeks 4-7 (up to 3 months) of illness
• Continued paroxysms of coughing due to irritation
• Cough persist despite appropriate treatment with
macrolide, but Rx likely decreases transmission
PERTUSSIS
 Diagnosis:
• Consider the diagnosis in unvaccinated children or in
adolescents/adults with waning immunity presenting with:
• Paroxysms of coughing after 2 weeks of illness
• Post-tussive vomiting
• Nasopharyngeal cultures – take 7-9 days
• Start empiric macrolide if suspicious
 Treatment:
• Macrolide: E-mycin or Azithromycin
• Post-exposure prophylaxis for close contacts (classmates)
 Prevention:
Prevent with appropriate vaccination!
Adults > age 19 need Tdap booster
EPSTEIN-BARR VIRUS (MONO)
EBV (aka human herpesvirus type 4)
• Causes fever, sore throat, adenopathy, fatigue
• Mononucleosis syndrome seen mostly in teens & young
adults (think high school & college students
• 50% of children are infected prior to age 5 (lucky!)
• Virus is detectable in saliva of 15-25% of individuals with past
infection
• Incubation period is 30-50 days
• Acute illness lasts about 2 weeks
• Fatigue may last weeks to [rarely] months
EPSTEIN-BARR VIRUS: PE
Retrieved from: http://www.adamimages.com/
EPSTEIN-BARR VIRUS: PE
Tonsillar exudates
Retrieved from: http://en.wikipedia.org/wiki/Tonsillitis
EPSTEIN-BARR VIRUS: PE
Tonsillar exudates
Retrieved from: http://en.wikipedia.org/wiki/Tonsillitis
EPSTEIN-BARR VIRUS: PE
• 50% have enlarged spleen
• Risk for spleen rupture if impact to abdomen
• no sports x 28 days
• 95% have elevated AST/ALT
• 2-3x over baseline
• Repeat LFTs in 4 weeks to ensure they have resolved
May see a maculopapular rash – acutely (more common in patients given
ampicillin/amoxicillin)
Erythema nodosum - later
EPSTEIN-BARR VIRUS: DX
Heterophile antibody (monospot)
can be done in the office – takes ~ 5 minutes
often not positive until 1-2 weeks after symptoms begin
EBV Panel (serum antibodies)
EBV IgM – elevated in acute phase, lasts ~ <12 weeks
if positive, patient has acute mono now
EBV IgG – after infection, remains positive for life
EPSTEIN-BARR VIRUS: RX
Supportive Care
Advil /Tylenol
“Magic Mouthwash”
No sports or vigorous physical activity x 4 weeks
If concern for impending airway obstruction
May give oral prednisone (40mg po x 7 days)
Controversial in infection/week data
Gives significant relieve for very sore throat
EPSTEIN-BARR VIRUS: DX
Differential Dx:
Group A strep pharyngitis
Other viruses that may cause a mono-like illness
CMV
Acute HIV
Toxoplasmosis
ACUTE HSV GINGIVOSTOMATITIS
Retrieved from:
http://www.gponline.com/basics-herpessimplex-virus/sexualhealth/herpes/article/1127162
Retrieved from:
http://www.pemcincinnati.com/blog/briefsapproach-patient-sore-throat/herpeticgingivostomatitis/
COXSACKIE VIRUSES
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Of the enterovirus family
Endemic in summer and fall
Transmitted in respiratory secretions & stool
Various strains cause:
URI symptoms
Hand-foot-mouth disease
Herpangina
Rash
COXSACKIE VIRUSES
Herpangina.
Retrieved from: http://diseasespictures.com/herpangina
COXSACKIE VIRUSES
Hand-foot-mouth disease
Hand-foot-mouth disease
Retrieved from: http://blogs.babycenter.com/wpcontent/uploads/2008/07/hand_foot_mouth_1_011216.jpg
Retrieved from: http://kdcq.com/hand-foot-mouthdisease-in-coos-county/
ORAL THRUSH
Retrieved from:
http://www.exodontia.info/Oral_Candidiasis.html
APTHOUS ULCERS
Retrieved from:
http://oralmaxillo-facialsurgery.blogspot.com/2010/05/aphthous-ulcers-2.html
MUCOCELE
Retrieved from: http://www.tuasaude.com/mucocele/
CONSIDER NEOPLASMS
Retreived from: http://www.mayoclinic.org/diseases-conditions/mouth-cancer/multimedia/lipcancer/img-20007508?_ga=1.169737761.1632205627.1423324290
REFERENCES
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Goroll
Merck Manual Professional
Mayo Clinic Foundation
Up to Date
IDSA Guidelines