1. Sore throat
Dr. duaa Hiasat

2. Clinical objectives
Describe the differential diagnosis of sore throat for patients of different ages.
Describe an evidence-based approach to diagnosis of strep throat and infectious mononucleosis that integrates the history and physical with judicious use of the laboratory.
Choose appropriate treatment for various causes of sore throat.

5. Definition
A sore throat is pain, scratchiness or irritation of the throat that often worsens with swallowing
About 4% of patient seeing a family physician report “sore throat “as the primary reason for causes .
It is the second –most common reason for an office visit .

6. Aetiology Infectious causes Noninfectious causes Bacterial(GABHS)
Viral (most)
Fungal
Gastroesophageal reflux
Postnasal drainage because allergic rhinitis and other upper respiratory conditions
acute thyroiditis
Persistent cough
Trauma
External
Internal
Referred dental pain

8. Viral infection
Most episodes of pharyngitis are caused by viruses ,including
Adenoviruses
Influenza viruses
Paraifluenza virus
Respiratory syncytial virus

9. Not necessary or important to determine the specific viruses responsible for the infection.
An exception Epstein-Barr virus infection, infectious mononucleosis, because of the protracted course and potentially serious complications of this illness such as :
(splenic rupture, respiratory compromise because severe tonsillar hypertrophy and cervical adenopathy)

10. Bacterial infections may be due to
GABHS most important of bacterial infection(because of it is rare but serious complication )
Group B and group C
Chlamydia pneumoniae
Branhamella species
Haemophilus species
Mycoplasma pneumoniae

12. HISTORY AND PHYSICAL EXAMINATION
CLINICAL EVALUATION
HISTORY AND PHYSICAL EXAMINATION

13. Should determine whether it is infectious or noninfectious :
noninfectious should be suspected in :
Afebrile
No other sign of upper respiratory tract infection
Longer duration than 1-2 weeks
And associated symptom with hurtburn ,itchy eyes ,postnasal drip
History of use antiacid
Symptome get worse late at night or early morning

14. Viral pharyngitis Fever Malaise Myalgias Headache
A runny or congested nose
Irritation or redness of the eyes
Cough, hoarseness,
soreness in the roof of the mouth

15. Bacteria –GABHS- Streptococcal pharyngitis
Fever>3ͦ8
NOcough,
Tonsillar enlargement
Tonsillar or pharyngeal exudate,
Anterior cervical adenopathy
Myalgias,
Recent strep exposure,
Brief duration of illness before presentation,
Headache also
Scarlatina rash (a fine sandpapery eruption

16. Bacteria –GABHS- Streptococcal pharyngitis
Pharyngeal injection
pharynx looks red.
Scarlatina rash (a fine sandpapery eruption)

17. Infection mononucleosis
Sore throat caused by Epestein-Barr virus-infection mononucleosis ,typically follows
a 30 – 50 day incubation period and a 3-5 day prodrome characterized by
Fever
Malaise
Myalgias
Headache
Cervical adenopathy
mainly posterior
Splenomegaly 50%
Palatal petechiae 50%
Jaundice 10% rash3%

18. F. NECROPHORUM PHARYNGITIS
Relatively little is known about the clinical diagnosis of F.necrophorum. Lemierre syndrome, the rare complication pharyngitis caused by F. necrophorum,
Disease of adolescents and young adults that typically begins 3–5 days after the onset of pharyngitis or tonsillitis.
The patient develops rigors and suppurative thrombophlebitis of the internal jugular vein, followed by
pulmonary abscesses.
Unilateral neck swelling in a patient with
symptoms of bacteremia several days after the onset of pharyngitis should trigger suspicion for Lemierre disease

20. When evaluating a patient with sore throat, be alert for red flags

21. Clinical Decision Rule
No individual item has sufficient predictive value on its own
Need to combine items to get greater predictive value
Purpose of a clinical decision rule
Centor or McIsaac Criteria

23. Diagnostic Testing

24. GABHS- Streptococcal pharyngitis
A variety of rapid antigen tests and cultures are available to test for the presence of GABHS bacteria in the pharynx.
Rapid antigen tests include enzyme immunoassays, latex agglutination tests, liposomal assays.
Although the throat culture test is often considered a gold standard.

25. Mononucleosis
Two types of laboratory tests are useful for confirming the diagnosis of infectious mononucleosis:
The complete blood-CBC count with differential,
A variety of serologic tests.

27. CBC
Lymphocytosis, which usually peaks 2 weeks after the onset of symptoms.
Atypical lymphocytes
More than 20% atypical lymphocytes, or
More than 50% lymphocytes with 10% or more atypical lymphocytes, infectious mononucleosis is quite likely, and further confirmation with serologic tests is not needed.
Serologic tests are often negative in the fir

28. Atypical Lymphocytes

29. Serologic Tests
are often negative in the first week of infection because they rely on the body’s immune response.
The traditional test is based on the fact that heterophil antibodies produced in patients with infectious mononucleosis agglutinate sheep erythrocytes; “Monospot” test is still widely used.
Rapid latex agglutination test based on the same principle.

30. Viral capsid antigen immunoglobulin M antibodies :
produced relatively early in infection and do not persist once the acute infection is over.
This test is quite sensitive and specific,
the sensitivity improves during the second week of the illness.
Other laboratory tests
aspartate aminotransferase (40 /L in 76% of patients)
alkaline phosphatase (elevated in 71% of patients)

31. MANAGEMENT

33. Viral pharyngitis Symptomatic treatment
Nonsteroidal anti-inflammatory drugs [NSAIDs] or Acetaminophen for fever and throat pain
Gargling with 2% viscous lidocaine for patients
with severe throat pain,
Over-the-counter (OTC) topical sprays (e.g., Chloraseptic spray)
Herbal tea has been shown in a randomized trial to be more effective than placebo

34. Approach: Clinical Suspicion based on Scoring above
Strep Score 4 to 5
Treat with antibiotics
Strep Score 2 to 3: Perform rapid antigen test
Antigen test positive: Treat with antibiotics
Antigen test negative: Throat Culture
Strep Score 0 to 1
Provide Pharyngitis Symptomatic Treatment

35. GABHS Pharyngitis

37. Child can return to school on the second day after the office visit .

38. Infectious Mononucleosis
Symptomatical treatment
Rest,
Oral fluids, and NSAIDs or acetaminophen for fever and myalgias.
Aspirin should be avoided because Of Reye syndrome has been reported in association with IM .
Corticosteroids for significant pharyngeal edema that causes or threatens respiratory compromise.

39. Participation in contact sports (e. g
Participation in contact sports (e.g., cheerleading, basketball, hockey, football, soccer) should be restricted during the acute phase of the illness and cont to be restricted at least 4 weeks and as long as the spleen is palpable
patient with coexisting strep pharyngitis based on sign and symptom should start AB other than amoxicillin

40. F. NECROPHORUM PHARYNGITIS
NO diagnostic test available to identify this agent .
So any patient adolescent or young adult with 3 or more of centor criteria should start empirically AB other than macraloids .

41. Complications

42. GABHS Pharyngitis 1. Suppurative bacteremia, cervical lymphadenitis,
endocarditis,
mastoiditis, meningitis, otitis media, peritonsillar or retropharyngeal abscess, and/or pneumonia
2.Non-Suppurative
Poststreptococcal
Glomerulonephritis
Rheumatic fever.

43. Scarlet fever Scarlet fever is associated with GABHS pharyngitis
punctate, erythematous, blanchable, sandpaper-like exanthem.
The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia’s lines).
 The pharynx and tonsils are erythematous and covered with exudates.
The tongue may be bright red with a white coating (strawberry tongue)

44. Scarlet fever

45. Infectious Mononucleosis
Splenomegaly- In extreme cases spleen rupture
Hepatitis. You may experience mild liver inflammation (hepatitis).
Jaundice. :
Anemia -Thrombocytopenia —
Heart problems —  (myocarditis)
Complications involving the nervous system — meningitis, encephalitis and Guillain-Barre syndrome
Enlarged tonsils -Respiratory compromise

46. PATIENT EDUCATION Several goals.
Patients should understand that only a minority of sore throats are caused by streptococcal pharyngitis or other bacteria,
Symptomatic treatment is usually sufficient.
They should also be told to relieve the symptoms of sore throat, using salt water gargles, NSAIDs, OTC throat sprays, and OTC lozenges (e.g., Chloraseptic ).

47. Case 1
A 7-year-old male presents with a 3-day history of sore throat, hoarseness, fever to 100°F (38°C), and cough. Your examination reveals injection of his tonsils, no exudates, shotty lymphadenopathy, and normal breath sounds. Which one of the following would be most appropriate? A) Symptomatic treatment only B) Empiric treatment for streptococcal pharyngitis C) A rapid antigen test for streptococcal pharyngitis D) A throat culture for streptococcal pharyngitis E) An office test for mononucleosis

48. Thanks