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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) • • • • 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 • • • • • 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: • • • • 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 • • • • 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 • • • • • Goroll Merck Manual Professional Mayo Clinic Foundation Up to Date IDSA Guidelines