1. PHARYNGITIS IN CHILDREN 林口長庚急診醫學部 吳孟書 醫師

2. Sore Throat  Any painful sensation localized to the pharynx or the surrounding areas.  Dysphagia  Difficult in swallowing

3. Differential Diagnosis of Sore Throat in the Host  Infectious pharyngitis Respiratory viruses Group A streptococci Epstein-Barr virus (infectious mononucleosis) Human immunodeficiency virus Neisseria gonorrhoeae Anaerobic bacteria (Lemierre ’ s disease) Group C and G streptococci (?) Arcabacterium hymolyticum (?) Mycoplasma pneumoniae (?) Clamydia pneumoniae (?) Francisella tularensis Corynebacterium diphtheriae (diphtheria)  Other causes Herpetic stomatitis Irritative pharyngitis Foreign body Peritonsillar abscess Retropheryngeal and lateral pharyngeal abscesses Epiglottitis Kawasaki disease Steven-Johnson syndrome Chemical exposure Psychogenic pain Referred pain Candida in immunosuppressed host

4. Common Causes of Sore Throat  Infectious pharyngitis Respiratory viruses Group A streptococci Epstein-Barr virus  Irritative pharyngitis

5. Life-Threatening Causes of Sore Throat  Retropharyngeal and lateral pharyngeal abscesses  Epiglottitis  Severe tonsillar hypertrophy with infectious mononucleosis  Diphtheria  Peritonsillar abscess  Lemierre ’ s syndrome

6. Diagnostic approach to the child with sore throat Respiratory distress? (Airway management) Epiglottitis Retropharyngeal or lateral pharyngeal abscess Peritonsillar abscess Tonsillar hypertrophy secondary to E-B virus Diphtheria (rare) YesNo Buccal/gingival inflammation? YesNo Viral stomatitis Steven-Johnson syndrome Behcet ’ s syndrome Foreign body seen? YesNo Foreign bodyUnilateral enlarged tonsil? YesNo Peritonsillar abscessPharynx inflamed? Yes No Irritative pheryngitis Psychogenic pharyngitis Referred pain Systemic illness with persist fever, conjunctivits, mucositis, and rash? NoYes Infectious pharyngitis (Fig. next) Kawasaki disease Steven-Johnson syndrome

7. Diagnostic approach to infectious pharyngitis in the immunocompetent child Vesicles on posterior pharynx? YesNo Herpangina (Coxackievirus) Prominent posterior cervical adenopathy? Diffuse adenopathy? NoYes Infectious mononucleosis (next Fig.) Human immunodeficiency virus Unusual history ( e.g. unimmunized, oral sexual contact)? YesNo Consider diphtheria or gonococcal pharyngitis Culture or rapid test Positive for Gr. A streptococci ? +- Streptococcal pharyngitisPersist inflammation ? NoYes Viral pharyngitisConsider I.M. (next Fig.) and uncommon etiologies (table 1)(table 1)

8. PHARYNGITIS  Nonstreptococcal pharyngitis --- Virus – most often --- Mycoplasma and Chlamydia --- Bcteria --- Fungus --- Protozoa  Streptococcal pharyngitis

9. DIPHTHERIA  C. diphtheriae  Rare  Immunization – DPT  Infectious invasion and spread -- pseudomembrane  Exotoxin  Dx – culture on Loeffler media  Tx – PCN or erythromycin plus horse- serum antitoxin

10. GONOCOCCAL PHARYNGITIS  N. gonorrhoeae  Child sexual abuse  Thayer-Martin medium  Rectal and vaginal or urethral culture  Syphilis and hepatitis B  Ceftriaxon – 125mg im once or TMP/SMX 5 days  Children > 9 y/o – plus doxycycline 100mg bid po for 7 days for chlamydia  Children < 8 y/o – plus erythromycin or azithromycin

11. INFECTIOUS MONONUCLEOSIS (IM)  Epstein-Barr virus  Fever, sore throat, adenopathy, hepatosplenomegaly  Exudative pharyngitis mimic streptococcal pharyngitis  Increased atypical lymphocytes in PB smear ( ≧ 50% lymphocyte, ≧ 10% atypical lymphocyte)  Heterophil antibody  EBV-specific serologic test – IgM and IgG response to EBV-VCA, and IgG to EBV early antigen and EBV nuclear antigen

12. Diagnostic approach when findings are clinically suggestive for mononucleosis Postive heterophil titer and/or typical white blood cell (WBC) count and differential? Yes No IM Diagnosis urgent ? Age < 5 years ? NoYes Positive heterophil titer and/or typical WBC count and differential after 1 week ? Epstein-Barr virus (EBV) – specific serology diagnostic of IM No YesNo Non-EBV IM syndromeIM Yes

13. INFECTIOUS MONONUCLEOSIS (IM)  Generally is a benign, self-limited, but somewhat prolonged illness  Supportive care  Severe complications: 一. Immunocompromised children  Airway obstruction – Dexan 1mg/kg stat then 0.5mg/kg q6h 三. Neurologic complications (e.g., menigoencephalitis, or Guillain-Barre ’ syndrome)  Splenic rupture and hemoorhage  Bacterial and fungal infections

14. STREPTOCOCCAL PHARYNGITIS  Common in 4 to 11 years old children  Sudden onset of fever and sore throat  Markedly red and exudative pharynx and tonsil  Petechiae over soft palate and uvula  Cervical LAP  Scarlatiniform rash  No significant cough and rhinorrhea  Throat swab for rapid antigen-detection and culture

15. STREPTOCOCCAL PHARYNGITIS  Treatment objectives: 一. Prevent suppurative complications  Prevent rheumatic fever 三. Hasten clinical recovery  Poststreptococcal glomerulonephritis – nonsuppurative complication  not preventable with antibiotic therapy  Antibiotic therapy begun within 9 days of the onset of infection  PCN, or cephalosporins, or clindamycin or macrolides

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