Case discussion R1 游俊豪

12 y/o male CC: Intermittent fever for 4 days Denied any previous systemic disease GA 31wk, BBW: 1900gm, twin BW: 49.5kg (>90 th percentile) Development: normal

Present illness 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.

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 IDSA practice guidelines for the diagnosis and management of group A streptococcal pharyngitis

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 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 beta- hemolytic 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 well- documented 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 MedicineIngrid U Scott, MD, MPH 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