1. Acute Pharyngitis
NURS 870

2. 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

3. 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

4. What not to miss Group A Strep due to its association with:
Peritonsillar abscess
Scarlet fever
Acute rheumatic fever
Acute glomerulonephritis

5. 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

6. 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

7. Group A strep: PE Tonsillar exudate 1
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8. Group A strep: PE Tonsillar exudate 2
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9. Group A strep: PE Palatal petechiae
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10. Group A strep: PE Anterior cervical adenopathy
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11. Group A strep: PE
Click here for scarlet fever rash images:

12. Group A strep: Dx
Click here for MD Calc Centor Score: 5 Criteria: Tonsillar exudate Tender/swollen anterior cervical nodes Fever > Absence of cough Age: Age Age Age >45 -1
Centor Criteria

13. 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

14. 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: U;
≥27 kg: 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.

15. 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.
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16. 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
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17. 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

18. 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

19. 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

20. 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: [
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

21. 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

22. 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 days
Acute illness lasts about 2 weeks
Fatigue may last weeks to [rarely] months

23. Epstein-barr virus: PE
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24. Epstein-barr virus: PE
Tonsillar exudates
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25. Epstein-barr virus: PE
Tonsillar exudates
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26. 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

27. 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

28. 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

29. Epstein-barr virus: Dx
Differential Dx: Group A strep pharyngitis Other viruses that may cause a mono-like illness CMV Acute HIV Toxoplasmosis

30. Acute HSV gingivostomatitis
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31. 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

32. Coxsackie Viruses Herpangina.
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33. Coxsackie Viruses Hand-foot-mouth disease Hand-foot-mouth disease
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Hand-foot-mouth disease
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34. Oral Thrush
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35. Apthous ulcers Retrieved from:

36. mucocele
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37. Consider neoplasms
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38. REferences Goroll Merck Manual Professional Mayo Clinic Foundation
Up to Date
IDSA Guidelines