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  1. 1. In The Name Of God Pharyngitis Dr.M.Karimi
  2. 2. PHARYNGITISPHARYNGITIS • What is itWhat is it?? – Inflammation of theInflammation of the Pharynx secondary to anPharynx secondary to an infectious agentinfectious agent – Most common infectiousMost common infectious agents are Group Aagents are Group A Streptococcus and variousStreptococcus and various viral agentsviral agents – Often co-exists withOften co-exists with tonsillitistonsillitis
  3. 3. EtiologyEtiology • Strep.AStrep.A • MycoplasmaMycoplasma • Strep.GStrep.G • Strep.CStrep.C • CorynebacteriumCorynebacterium diphteriaediphteriae • ToxoplasmosisToxoplasmosis • GonorrheaGonorrhea • TularemiaTularemia • RhinovirusRhinovirus • CoronavirusCoronavirus • AdenovirusAdenovirus • CMVCMV • EBVEBV • HSVHSV • EnterovirusEnterovirus • HIVHIV
  4. 4. Acute PharyngitisAcute Pharyngitis • EtiologyEtiology – Viral >90%Viral >90% • Rhinovirus – common coldRhinovirus – common cold • Coronavirus – common coldCoronavirus – common cold • Adenovirus – pharyngoconjunctivalAdenovirus – pharyngoconjunctival fever;acute respiratory illnessfever;acute respiratory illness • Parainfluenza virus – common cold;Parainfluenza virus – common cold; croupcroup • Coxsackievirus - herpanginaCoxsackievirus - herpangina • EBV – infectious mononucleosisEBV – infectious mononucleosis • HIVHIV
  5. 5. Acute PharyngitisAcute Pharyngitis • EtiologyEtiology – BacterialBacterial • Group A beta-hemolytic streptococci (Group A beta-hemolytic streptococci (S.S. pyogenespyogenes)*)* – most common bacterial cause of pharyngitismost common bacterial cause of pharyngitis – accounts for 15-30% of cases in children and 5-10%accounts for 15-30% of cases in children and 5-10% in adults. • Mycoplasma pneumoniaeMycoplasma pneumoniae • Arcanobacterium haemolyticumArcanobacterium haemolyticum • Neisseria gonorrheaNeisseria gonorrhea • Chlamydia pneumoniaeChlamydia pneumoniae
  6. 6. PHARYNGITISPHARYNGITIS • HISTORYHISTORY – Classic symptoms →Classic symptoms → Fever, throat pain, dysphagiaFever, throat pain, dysphagia VIRAL →VIRAL → Most likely concurrent URI symptoms ofMost likely concurrent URI symptoms of rhinorrhearhinorrhea, cough, hoarseness,, cough, hoarseness, conjunctivitisconjunctivitis && ulcerative lesionsulcerative lesions STREPSTREP → Look for associated→ Look for associated headacheheadache, and/or, and/or abdominal painabdominal pain  Fever and throat pain are usuallyFever and throat pain are usually acute in onsetacute in onset
  7. 7. PHARYNGITISPHARYNGITIS • Physical ExamPhysical Exam – VIRALVIRAL EBVEBV –– White exudateWhite exudate covering erythematouscovering erythematous pharynx and tonsils,pharynx and tonsils, cervical adenopathycervical adenopathy,,  Subacute/chronic symptoms (fatigue/myalgias)Subacute/chronic symptoms (fatigue/myalgias)  transmitted via infected salivatransmitted via infected saliva Adenovirus/CoxsackieAdenovirus/Coxsackie – vesicles/ulcerative lesions– vesicles/ulcerative lesions present on pharynx or posterior soft palatepresent on pharynx or posterior soft palate  Also look for conjunctivitisAlso look for conjunctivitis
  8. 8. Epidemiology of StreptococcalEpidemiology of Streptococcal PharyngitisPharyngitis • Spread by contact with respiratory secretionsSpread by contact with respiratory secretions • Peaks in winter and springPeaks in winter and spring • School age child (5-15 y)School age child (5-15 y) • Communicability highest during acute infectionCommunicability highest during acute infection • Patient no longer contagious after 24 hours ofPatient no longer contagious after 24 hours of antibioticsantibiotics • If hospitalized, droplet precautions needed untilIf hospitalized, droplet precautions needed until no longer contagiousno longer contagious
  9. 9. PHARYNGITISPHARYNGITIS • Physical ExamPhysical Exam – BacterialBacterial GASGAS – look for whitish exudate covering pharynx– look for whitish exudate covering pharynx and tonsilsand tonsils – tender anterior cervical adenopathytender anterior cervical adenopathy – palatal/uvularpalatal/uvular petechiaepetechiae – scarlatiniform rash covering torso and upperscarlatiniform rash covering torso and upper armsarms Spread viaSpread via respiratory particle dropletsrespiratory particle droplets – NO– NO school attendance untilschool attendance until 24 hours after24 hours after initiation ofinitiation of appropriate antibiotic therapyappropriate antibiotic therapy – Absence of viral symptoms (rhinorrhea, cough,Absence of viral symptoms (rhinorrhea, cough, hoarseness)hoarseness)
  10. 10. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis • Pharyngeal exudates:Pharyngeal exudates: – S. pyogenesS. pyogenes – C. diphtheriaeC. diphtheriae – EBVEBV
  11. 11. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis • Skin rash:Skin rash: – S. pyogenesS. pyogenes – HIVHIV – EBVEBV
  12. 12. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis • Conjunctivitis:Conjunctivitis: – AdenovirusAdenovirus
  13. 13. Suppurative Complications ofSuppurative Complications of Group A Streptococcal PharyngitisGroup A Streptococcal Pharyngitis • Otitis mediaOtitis media • SinusitisSinusitis • Peritonsillar and retropharyngealPeritonsillar and retropharyngeal abscessesabscesses • Suppurative cervical adenitisSuppurative cervical adenitis
  14. 14. Streptococcal Cervical AdenitisStreptococcal Cervical Adenitis
  15. 15. Nonsuppurative Complications ofNonsuppurative Complications of Group A StreptococcusGroup A Streptococcus • Acute rheumatic feverAcute rheumatic fever – follows only streptococcal pharyngitis (notfollows only streptococcal pharyngitis (not group A strep skin infections)group A strep skin infections) • Acute glomerulonephritisAcute glomerulonephritis – May follow pharyngitis or skin infectionMay follow pharyngitis or skin infection (pyoderma)(pyoderma) – Nephritogenic strainsNephritogenic strains
  16. 16. PharyngitisPharyngitis
  17. 17. Infectious MononucleosisInfectious Mononucleosis
  18. 18. HerpanginaHerpangina
  21. 21. pharyngitispharyngitis
  22. 22. Scarlatiniform RashScarlatiniform Rash
  23. 23. Clinical manifestationClinical manifestation (Strep.)(Strep.) • Rapid onsetRapid onset • HeadacheHeadache • GI SymptomsGI Symptoms • Sore throatSore throat • ErythmaErythma • ExudatesExudates • Palatine petechiaePalatine petechiae • Enlarged tonsilsEnlarged tonsils • Anterior cervicalAnterior cervical adenopathy &Tenderadenopathy &Tender • Red& swollen uvulaRed& swollen uvula
  24. 24. Clinical manifestationClinical manifestation (Viral)(Viral) • Gradual onsetGradual onset • RhinorrheaRhinorrhea • CoughCough • DiarrheaDiarrhea • FeverFever
  25. 25. Clinical manifestationClinical manifestation • Vesiculation & Ulceration HSVVesiculation & Ulceration HSV GingivostomatitisGingivostomatitis CoxsackievirusCoxsackievirus • Cnonjunctivitis AdenovirusCnonjunctivitis Adenovirus • Gray-white fibrinous pseudomembraneGray-white fibrinous pseudomembrane With marked cervical lymphadenopathy DiphteriaWith marked cervical lymphadenopathy Diphteria • Macular rash Scarlet feverMacular rash Scarlet fever • Hepatosplenomegally &RashHepatosplenomegally &Rash &Fatigue &Cervical lymphadenitis EBV&Fatigue &Cervical lymphadenitis EBV
  26. 26. DiagnosisDiagnosis • Strep:Strep: Throat culture(GoldThroat culture(Gold stndard)stndard) Rapid Strep. Antigen kitsRapid Strep. Antigen kits • Infectious Mono.:Infectious Mono.: CBC(Atypical lymphocytes)CBC(Atypical lymphocytes) Spot test (Positive slideSpot test (Positive slide agglutination)agglutination) • Mycoplasma:Mycoplasma: Cold agglutination testCold agglutination test
  27. 27. Differential diagnosisDifferential diagnosis • Retropharyngeal abscessesRetropharyngeal abscesses • Peritonsilar abscessesPeritonsilar abscesses • Ludwig anginaLudwig angina • EpiglotitisEpiglotitis • ThrushThrush • Autoimmune ulcerationAutoimmune ulceration • KawasakiKawasaki
  28. 28. TreatmentTreatment ((Antibiotic ,Acetaminophen ,Warm salt gargling)Antibiotic ,Acetaminophen ,Warm salt gargling) • Strep:Strep: PenicillinPenicillin ,Erythromycin , Azithromycin,Erythromycin , Azithromycin • Carrier of strep:Carrier of strep: ClindamycinClindamycin ,Amoxicillin clavulanic,Amoxicillin clavulanic • Retropharyngeal abscesses:Retropharyngeal abscesses: Drainage + AntibioticsDrainage + Antibiotics • Peritonsilar abscesses:Peritonsilar abscesses: penicillin + Aspirationpenicillin + Aspiration
  29. 29. Recurrent pharyngitisRecurrent pharyngitis • Etiology: Nonpenicillin treatment ,DifferentEtiology: Nonpenicillin treatment ,Different strain ,Another cause pharyngitisstrain ,Another cause pharyngitis • Treatment:Treatment: TonsilectomyTonsilectomy ifif Culture positive, severe GABHS more thanCulture positive, severe GABHS more than 7 times during previous year7 times during previous year oror 5 times each year during two previous year5 times each year during two previous year
  30. 30. Benefit of treatment of Strep.Benefit of treatment of Strep. PharyngitisPharyngitis • 1-Prevention of ARF if treatment started1-Prevention of ARF if treatment started within 9 days of illnesswithin 9 days of illness • 2-Reduce symptoms2-Reduce symptoms • 3-Prevent local suppurative complications3-Prevent local suppurative complications BUTBUT Does not prevent the development of theDoes not prevent the development of the post streptococcal sequel of acutepost streptococcal sequel of acute glomerulonephritisglomerulonephritis
  31. 31. Antibiotic started immediately with symptomaticAntibiotic started immediately with symptomatic pharyngitis and positive Rapid testpharyngitis and positive Rapid test (Without culture)(Without culture) • 1-Clinical diagnosis of scarlet fever1-Clinical diagnosis of scarlet fever • 2-Household contact with documented2-Household contact with documented strep. Pharyngitisstrep. Pharyngitis • 3-Past history of ARF3-Past history of ARF • 4-Recent history of ARF in a family4-Recent history of ARF in a family membermember
  32. 32. PHARYNGITISPHARYNGITIS • LAB AIDSLAB AIDS  Rapid strep antigen → detects GAS antigenRapid strep antigen → detects GAS antigen Tonsillar swab → 3-5 minutes to performTonsillar swab → 3-5 minutes to perform • 95% specificity, 90-93% sensitivity95% specificity, 90-93% sensitivity  GAS Throat culture → “gold standard”GAS Throat culture → “gold standard” • >95% sensitivity>95% sensitivity  Mono Spot → serologic test for EBV heterophile AbMono Spot → serologic test for EBV heterophile Ab  EBV Ab titers → detect serum levels of EBV IgM/IgGEBV Ab titers → detect serum levels of EBV IgM/IgG
  33. 33. PHARYNGITISPHARYNGITIS • TreatmentTreatment VIRAL –VIRAL – Supportive care only – Analgesics,Supportive care only – Analgesics, Antipyretics, FluidsAntipyretics, Fluids  No strong evidenceNo strong evidence supporting use of oral orsupporting use of oral or intramuscular corticosteroids for pain relief → fewintramuscular corticosteroids for pain relief → few studies show transient relief within first 12–24 hrsstudies show transient relief within first 12–24 hrs after administrationafter administration EBV – infectious mononucleosisEBV – infectious mononucleosis  activity restrictions – mortality in these pts mostactivity restrictions – mortality in these pts most commonly associated with abdominal trauma and spleniccommonly associated with abdominal trauma and splenic rupturerupture
  34. 34. PHARYNGITISPHARYNGITIS • TreatmentTreatment →→ Do so to preventDo so to prevent ARFARF (Acute Rheumatic Fever)(Acute Rheumatic Fever) GASGAS →→ Oral PCN – treatment of choiceOral PCN – treatment of choice 10 day course of therapy10 day course of therapy IM Benzathine PCN G – 1.2 million units x 1IM Benzathine PCN G – 1.2 million units x 1 Azithromycin, Clindamycin, or 1Azithromycin, Clindamycin, or 1stst generationgeneration cephalosporins for PCN allergycephalosporins for PCN allergy
  35. 35. Group A StreptococcusGroup A Streptococcus
  36. 36. Group A Beta HemolyticGroup A Beta Hemolytic StreptococcusStreptococcus
  37. 37. Strawberry Tongue in ScarletStrawberry Tongue in Scarlet FeverFever
  38. 38. Scarlet FeverScarlet Fever • Occurs most commonly in associationOccurs most commonly in association with pharyngitiswith pharyngitis – Strawberry tongueStrawberry tongue – RashRash • Generalized fine, sandpapery scarlet erythemaGeneralized fine, sandpapery scarlet erythema with accentuation in skin folds (Pastia’s lines)with accentuation in skin folds (Pastia’s lines) • Circumoral pallorCircumoral pallor • Palms and soles sparedPalms and soles spared – Treatment same as strep pharyngitisTreatment same as strep pharyngitis
  39. 39. Rash of Scarlet FeverRash of Scarlet Fever
  40. 40. Acute Rheumatic FeverAcute Rheumatic Fever • Immune mediated - ?humoralImmune mediated - ?humoral • Diagnosis by Jones criteriaDiagnosis by Jones criteria – 5 major criteria5 major criteria • CarditisCarditis • Polyarthritis (migratory)Polyarthritis (migratory) • Sydenham’s choreaSydenham’s chorea – muscular spasms, incoordination, weaknessmuscular spasms, incoordination, weakness • Subcutaneous nodulesSubcutaneous nodules – painless, firm, near bony prominencespainless, firm, near bony prominences • Erythema marginatumErythema marginatum
  41. 41. Erythema Marginatum
  42. 42. Acute Rheumatic FeverAcute Rheumatic Fever • Minor manifestationsMinor manifestations – Clinical FindingsClinical Findings • arthralgiaarthralgia • feverfever – Laboratory FindingsLaboratory Findings • Elevated acute phase reactantsElevated acute phase reactants – erythrocyte sedimentation rateerythrocyte sedimentation rate – C-reactive proteinC-reactive protein • Prolonged P-R interval on EKGProlonged P-R interval on EKG
  43. 43. Acute Rheumatic FeverAcute Rheumatic Fever • Supporting evidence of antecedent group ASupporting evidence of antecedent group A streptococcal infectionstreptococcal infection – Positive throat culture or rapidPositive throat culture or rapid streptococcal antigen teststreptococcal antigen test – Elevated or rising streptococcal antibodyElevated or rising streptococcal antibody titertiter • antistreptolysin O (ASO), antiDNAse Bantistreptolysin O (ASO), antiDNAse B • If evidence of prior group A streptococcalIf evidence of prior group A streptococcal infection, 2 major or one major and 2 minorinfection, 2 major or one major and 2 minor manifestations indicates high probability ofmanifestations indicates high probability of ARF
  44. 44. Acute Rheumatic FeverAcute Rheumatic Fever • TherapyTherapy – Goal: decrease inflammation, fever andGoal: decrease inflammation, fever and toxicity and control heart failuretoxicity and control heart failure – Treatment may include anti-inflammatoryTreatment may include anti-inflammatory agents and steroids depending on severityagents and steroids depending on severity of illnessof illness
  45. 45. PoststreptococcalPoststreptococcal GlomerulonephritisGlomerulonephritis • Develops about 10 days afterDevelops about 10 days after pharyngitispharyngitis • Immune mediated damage to theImmune mediated damage to the kidney that results in renal dysfunctionkidney that results in renal dysfunction • Nephritogenic strain ofNephritogenic strain of S. pyogenesS. pyogenes
  46. 46. PoststreptococcalPoststreptococcal GlomerulonephritisGlomerulonephritis • Clinical PresentationClinical Presentation – Edema, hypertension, and smoky or rustyEdema, hypertension, and smoky or rusty colored urinecolored urine – Pallor, lethargy, malaise, weakness,Pallor, lethargy, malaise, weakness, anorexia, headache and dull back painanorexia, headache and dull back pain – Fever not prominentFever not prominent • Laboratory FindingsLaboratory Findings – Anemia, hematuria, proteinuriaAnemia, hematuria, proteinuria – Urinalysis with RBCs, WBCs and castsUrinalysis with RBCs, WBCs and casts
  47. 47. PoststreptococcalPoststreptococcal GlomerulonephritisGlomerulonephritis • DiagnosisDiagnosis – Clinical history, physical findings, andClinical history, physical findings, and confirmatory evidence of antecedentconfirmatory evidence of antecedent streptococcal infection (ASO or anti-DNAse B)streptococcal infection (ASO or anti-DNAse B) • TherapyTherapy – Penicillin to eradicate the nephritogenicPenicillin to eradicate the nephritogenic streptococci (erythromycin if allergic)streptococci (erythromycin if allergic) – Supportive care of complicationsSupportive care of complications
  48. 48. DiphtheriaDiphtheria • Etiologic agent: CorynebacteriumEtiologic agent: Corynebacterium diphtheriadiphtheria – Extremely rare, occurs primarily inExtremely rare, occurs primarily in unimmunized patientsunimmunized patients – Gram positive rodGram positive rod – nonspore formingnonspore forming – strains may be toxigenic or nontoxigenicstrains may be toxigenic or nontoxigenic • exotoxin required for diseaseexotoxin required for disease
  49. 49. Corynebacterium DiphtheriaeCorynebacterium Diphtheriae
  50. 50. TONSILLITISTONSILLITIS Inflammation/Infection of the tonsilsInflammation/Infection of the tonsils  Palatine tonsilsPalatine tonsils → visible during oral exam→ visible during oral exam Also have pharyngeal tonsils (adenoids) and lingual tonsilsAlso have pharyngeal tonsils (adenoids) and lingual tonsils • HistoryHistory → sore throat, fever, otalgia, dysphagia→ sore throat, fever, otalgia, dysphagia • Physical ExamPhysical Exam → whitish plaques, enlarged/tender→ whitish plaques, enlarged/tender cervical adenopathycervical adenopathy • EtiologyEtiology → GAS, EBV – less commonly HSV→ GAS, EBV – less commonly HSV • TreatmentTreatment → same as for pharyngitis→ same as for pharyngitis
  53. 53. LARYNGITISLARYNGITIS • Inflammation of the mucous membranesInflammation of the mucous membranes covering the larynx with accompaniedcovering the larynx with accompanied edema of the vocal cordsedema of the vocal cords  HistoryHistory →→ sore throatsore throat,, dysphoniadysphonia (hoarseness) or(hoarseness) or loss of voiceloss of voice, cough, possible, cough, possible low-grade feverlow-grade fever  Physical ExamPhysical Exam →→ cannot directly visualize larynx on standard PEcannot directly visualize larynx on standard PE must use fiberoptic laryngoscopy (not usuallymust use fiberoptic laryngoscopy (not usually necessary )necessary )
  54. 54. LARYNGITISLARYNGITIS • ETIOLOGYETIOLOGY →→  AcuteAcute [<3wks duration]– Think infectious → most[<3wks duration]– Think infectious → most commonly viral – symptoms most commonly resolvecommonly viral – symptoms most commonly resolve in 7-10 daysin 7-10 days  ChronicChronic [>3wks duration]– Inhalation of irritant fumes,[>3wks duration]– Inhalation of irritant fumes, vocal misuse, GERD, smokersvocal misuse, GERD, smokers TreatmentTreatment → symptomatic care → complete→ symptomatic care → complete voice rest, avoid exposure to insulting agent,voice rest, avoid exposure to insulting agent, anti-reflux therapyanti-reflux therapy Prevailing dataPrevailing data does NOT supportdoes NOT support the use ofthe use of corticosteroids for symptomatic reliefcorticosteroids for symptomatic relief
  55. 55. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS  Accumulation of pus in the tonsillar fossa → thought to be anAccumulation of pus in the tonsillar fossa → thought to be an infectious complication of inappropriately treatedinfectious complication of inappropriately treated pharyngitis/tonsillitispharyngitis/tonsillitis  HistoryHistory →→ Antecedent sore throat 1-2 wks prior - progressively worsensAntecedent sore throat 1-2 wks prior - progressively worsens DysphagiaDysphagia High feverHigh fever Ipsilateral throat, ear & possibly neck painIpsilateral throat, ear & possibly neck pain  Physical ExamPhysical Exam →→  Trismus – 67% of casesTrismus – 67% of cases  muffled voice (“Hot Potato”)muffled voice (“Hot Potato”)  Drooling &/or fetid breathDrooling &/or fetid breath  look for unilateral mass in the supratonsilar area with possible uvulalook for unilateral mass in the supratonsilar area with possible uvula deviationdeviation  fluctuant upon palpationfluctuant upon palpation
  56. 56. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS  EtiologyEtiology →→ 90% of aspirated cultures grow bacterial pathogens90% of aspirated cultures grow bacterial pathogens  GAS – most common (approximately 30% of cases)GAS – most common (approximately 30% of cases)  Staphylococcus aureusStaphylococcus aureus  Anaerobes – most commonly Peptostreptococcal microbesAnaerobes – most commonly Peptostreptococcal microbes  TreatmentTreatment →→  Prompt ENT consultation forPrompt ENT consultation for needle aspirationneedle aspiration (*always(*always send cultures) or possible surgical drainagesend cultures) or possible surgical drainage  Systemic abx –Systemic abx – usually Clindamycinusually Clindamycin andand aa ββ-Lactam or-Lactam or 11stst generation cephalosporingeneration cephalosporin  Surgical tonsillectomy if:Surgical tonsillectomy if: 1)1) No improvement in 48 hoursNo improvement in 48 hours 2)2) H/O recurrent abscesses – 3 or more (controversial)H/O recurrent abscesses – 3 or more (controversial)
  57. 57. Bilateral peritonsillar abscesses