1. Case Objectives Familiarize the learner with the Centor Criteria and demonstrate how they can help guide when an expanded clinical assessment and investigation pathway is warranted Review differential diagnosis for acute sore throat The patient is a 26 year-old obese female with asthma who attended our walk-in clinic with the symptoms of sore throat, right ear pain, and trouble swallowing for three days. She had nasal discharge with thick, white sputum but denied cough. She denied fever, tinnitus, cough, hemoptysis and sick contacts. She had not traveled recently. She felt her symptoms were different from her asthma. One month prior to her presentation she had similar symptoms. She took five days amoxicillin, which she happened to have at home, with apparent improvement in symptoms. Centor criteria Discussion Conclusions When it isn’t Streptococcus – utilizing the Centor criteria in a young patient with sore throat H Ali & L Rucker Jacobi Medical Center & Albert Einstein College of Medicine, Bronx, New York. Department of Internal Medicine ●Tonsillar exudates ●Tender anterior cervical adenopathy ●Fever > 100.5 by history ●Absence of cough If 3 or 4 of Centor criteria are met, the positive predictive value is 40% to 60%. The absence of 3 or 4 of the Centor criteria has a fairly high negative predictive value of 80% [1] See table for details Physical examination was significant for the following: Temperature: 98.1Pulse 57 Respirations 14 Blood Pressure 138/88 Ear: normal tympanic membrane; Nose: inflamed turbinates; Throat: enlarged, red tonsils with white exudates bilaterally; Neck: no adenopathy; Skin: no rash. Because only two of the four Centor criteria were positive and the diagnosis of group A Streptococcus was improbable, we obtained more historical information. The patient described having oral sex with her partner about 3 days prior to the onset of symptoms and recalled the same timing of symptoms after the same sexual contact one month prior. We performed nucleic acid amplification testing for neisseria gonorrhea and chlamydia trachomatis, and the former was positive. A single injection of ceftriaxone cured her infection. The likelihood of having group A Streptococcal infection increases with the number of Centor criteria. Patients having two or fewer of the criteria are not likely to have the infection so testing and treatment costs can be saved. In this scenario, other causes must be entertained. The differential diagnosis of sore throat includes viruses (HIV, Herpes, Epstein-Barr), bacteria (other Streptococci, Fusobacteria, Corynebacterium, Neisseria, Francisella, Mycoplasma), and non- infections (toxins, allergens, stomach acid). In this case we asked about sexual practices, HIV risks, and rashes before testing for gonorrhea and other sexually transmitted infections. Gonococcal pharyngitis is seen most often in people who practice oral sex. There are no pathognomonic findings with gonococcal pharyngitis. It is more likely after fellatio than cunnilingus. The prevalence of infection in patients with sore throat is 2-6%. Asymptomatic infections are common. Besides pharyngitis, Gonococcal infection can manifest as cervicitis, urethritis, pelvic inflammatory disease, epididymitis, proctitis, Bartholin gland infection, and disseminated disease. In this case, application of the Centor criteria appropriately broadened our differential diagnosis and helped us highlight risk factors for less common pathogens. [1] Guideline for the management of acute sore throat. AUESCMID Sore Throat Guideline Group, Pelucchi C et al. Clin Microbiol Infect. 2012 Apr;18 Suppl 1:1-28 References Introduction Antimicrobials should be restricted in sore throat to minimize medication related side effects, the effect of antibiotics on microbiota, antibacterial resistance, medicalization and costs. The Centor Criteria were developed in 1981 as an aide to the correct diagnosis of group A Streptococcal sore throat. When suspected, timely antibiotic treatment can reduce the risk of complications such as acute rheumatic fever or acute glomerulonephritis. Number of signs / symptomsRisk of Group A Strep Infection (%) 456 332 215 16.5 02.5