Acute Pharyngitis NURS 870

Objectives Students will be able to: Identify the most common causes of pharyngitis in the outpatient setting. Evaluate for possible Group A strep infection Identify possible complications of untreated Group A Strep Identify & treat other common causes of acute pharyngitis

Common causes Bacteria Viruses Fungi (candida) Other oral lesions 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/Scarletfever.htm

Group A strep: Dx Click here for MD Calc Centor Score: http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/ 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: Treat with antibiotics Score 2-3: Rapid strep antigen test If positive: treat with antibiotics If negative: throat culture Score 0-1: Symptomatic pharyngitis treatment Centor Criteria

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 BID or TID x 10 d adolescents/adults: 250 QID or 500 mg BID x 10 d Strong, high Amoxicillin, oral 50 mg/kg once daily (max = 1000 mg) x 10 d alt: 25 mg/kg BID x 10 d (max = 500 mg) x10 d Strong, high Benzathine penicillin G, IM <27 kg: 600 000 U; ≥27 kg: 1 200 000 U 1 dose Strong, high For individuals with penicillin allergy Cephalexin,b oral 20 mg/kg/dose BID (max = 500 mg/dose) x 10 d Strong, high Cefadroxil,b oral 30 mg/kg once daily (max = 1 g) x 10 d Strong, high Clindamycin, oral 7 mg/kg/dose TID (max = 300 mg/dose) x 10 d Strong, moderate Azithromycin,c oral 12 mg/kg once daily (max = 500 mg) x 5 d Strong, mod Clarithromycin,c oral 7.5 mg/kg/dose BID (max = 250 mg/dose) x 10 d Strong, moderate b Avoid in individuals with immediate type hypersensitivity to penicillin. c 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 - migratory polyarthritis heart - 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/gram-negative_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-herpes-simplex-virus/sexual-health/herpes/article/1127162 Retrieved from: http://www.pemcincinnati.com/blog/briefs-approach-patient-sore-throat/herpetic-gingivostomatitis/

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/wp-content/uploads/2008/07/hand_foot_mouth_1_011216.jpg Hand-foot-mouth disease Retrieved from: http://kdcq.com/hand-foot-mouth-disease-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/lip-cancer/img-20007508?_ga=1.169737761.1632205627.1423324290

REferences Goroll Merck Manual Professional Mayo Clinic Foundation Up to Date IDSA Guidelines