What to do and when to do it?? The sore throat What to do and when to do it??

Introduction Sore throat is among the top 10 reasons for patients presenting to their GP. The rate of sore throat presentation to GP’s is approx 3.6 per 100 encounters. Common causes Viral pharyngitis-most common cause Streptococcal pharyngitis Infectious mononucleosis

Continued.. Life threatening less common causes Epiglottitis Retropharyngeal abscess Lateral pharyngeal abscess Peritonsillar abscess Diphtheria

How to Diagnose? 1)Careful history taking Key historical variables include Rapidity and onset of symptoms Respiratory distress Fever (history of as well as current) Fatigue

Continued.. Key observations Stridor/Drooling Inflammation 2) Careful Physical Examination Key observations Stridor/Drooling Inflammation Asymmetry of tonsils Exudates (tonsils) Foreign body Swollen anterior cervical nodes Palatal petechiae Erythema

The case PC-6 year old NZE girl presents with sudden onset of wide spread rash. HPC-3/7 hx sore throat, fever and 3x random vomits. Now afebrile, feeling better but has rash present. Describes rash as “prickly” , denies itch. Denies headache or other pain or discomfort. Denies nausea or diarrhoea, stated had normal BM this morning. Denies urinary symptoms. Normal diet. No other household members unwell

continued.. Meds- nil NKA PMHx- Fully immunised, no PMHx of note. FHx-No FHx of note SHx- Lives at home with both parents and two older siblings. Attends school, no concerns.

The Examination O/E- Looks well, well perfused. Temp -36.8 (no recent antipyretic) RR- 18 Pulse- 106 Weight- 25kg Height- 115cm Ears - NAD, TM visualized, good cone of light . Throat- Mildly red, R) tonsil enlarged (mother states it has always been bigger than L), no exudates noted. Tongue red with red papillae.

Continued.. Lymph nodes-Tonsillar lymph nodes palpable. Other cervical and axilla nodes NAD Skin- wide spread punctiform erythematous blanching rash over trunk and legs. Kerning's sign negative. Chest - Breath sounds vesicular, no wheeze or rhonchi noted

Differential Diagnosis Post viral (pharyngitis )rash Streptococcal pharyngitis Epstein Barr Virus, Cytomegalovirus Adenovirus Influenza

Plan Swab throat Advise rest, fluids, paracetamol for comfort/fever if required. Remain absent from school until rash resolves Return to or contact medical centre if her condition deteriorates or symptoms change Discuss management plan with GP

Follow UP/management 24 hours later the throat swab culture result was in. It showed a heavy growth of Streptococcus pyogenes.Its sensitivities were Clindamycin, Erythromycin and Penicillin. Mother was informed and pt was prescribed Amoxicillin 250mg/5mls- 5mls tds for 10days. A further f/u phone call 2/7 later and pt was well and happy with no complaints.

Group A Streptococcus GAS is the most common cause of bacterial pharyngitis and accounts for 15-30% all cases of pharyngitis in children aged 5-15. Incubation period is 2-4 days and signs and symptoms last from 3-5 days Transmission from infectious person to close contacts is approx 35%.Children most infectious during acute phase & can continue to be infectious for up to 2/52. Common Signs & Symptoms- abrupt onset of sore throat, tonsillar exudate, fever, cervical adenopathy ,palatial petechiae, scarlatiniform rash (unusual) .

Continued.. Complications Acute Rheumatic Fever- 15 cases per 100,000 children aged 5 to 15 years of age. Glomerulonephritis-uncommon PANDAS Syndrome- Paediatric autoimmune neuropsychiatric disorder-uncommon

Diagnosis of GAS Who should be tested? Use scoring system, 1 point for each: Age (5-15 years) Season (late autumn, winter, early spring) Evidence of acute pharyngitis( erythema, edema and/or exudates) Tender enlarged anterior cervical nodes Absence of usual viral upper respiratory tract infections A score of six has likelihood of GAS of 85%

Continued..

Continued.. The diagnosis of GAS needs to be confirmed microbiologically prior to treatment initiation to minimise overuse of antibiotics. Gold standard is a throat culture –sensitivity is 90-95% for GAS Rapid streptococcal antigen test (RSAT)

Treatment GAS needs to be confirmed by culture or RSAT . HOWEVER, in some cases (i.e. lab results will be delayed or child is high risk Maori or Pacific island) if clinical and/or epidemiologic point to high index o suspicion for GAS it is appropriate to initiate antimicrobial therapy. If swab returns negative result antimicrobial therapy should be stopped. A delay in treatment of up to 9 days following onset of symptoms is still helpful in the prevention of ARF

Antibiotics Penicillin ( includes ampicillin and amoxicillin) Cephalosporin Macrolides Clindamycin

dosing Oral penicillin V (on empty stomach) for ten days- children 20mg/kg per day in two to three divided doses with a maximum of 500mg three times daily , adults 500mg twice daily Oral amoxicillin for ten days -750mg once daily if < 30kg, or 1500mg once daily if >30kg- doses can be divided if compliance is not a concern

Bacteriological relapse and Clinical Recurrence Both are minimal Bacteriological Relapse- 2-7 % after 28-35 days Clinical Recurrence- 1% after 28-35 days

Summary Score patient- history and physical examination -to assess likelihood of GAS. Obtain swab culture or RSTAT prior to commencing treatment is best practice. If delay in culture likely or pt high risk, initiate treatment at consultation. Amoxicillin or Penicillin for 10 days is best practice.

References The reference list has been emailed to the course convener