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Uri presentation 4 23-19
- 1. Upper Respiratory Tract Infections: Pharyngitis,Epiglottitis, Deep Infections in Head and Neck Wednesday April 23, 2019 Resident Noon Conference Series Sophie Woolston, MD
- 2. Agenda • Pharyngitis • (briefly): •Epiglottitis • Deep neck space infections • For PCPs: • for pharyngitis: stop using so many antibiotics, but use them when you need to!
- 4. 30 year oldintern presents with a sore throat • Fever to 101.3 x 24 hours • No cough On exam: -- tender LNs -- no tonsillar exudates
- 5. Centor Criteria • IsGroup A beta-haemolytic streptococcus as a cause of presentation with sore throat??: • Tonsillar exudate • Tender anterior cervical LAD • Abscess of cough • Fever • Presence of 3 or 4 have a 40-60% likelihood of having GABHS as the cause. • Absence of 3 or 4 suggests there is an 80% chance that GABHS is not the cause
- 6. What work up? •3 or 4 Centor criteria: RADT without backup throat culture (positive RADT is specific and will allow for rapid initiation of antibiotic treatment). Good neg predictive value • RADT sensitivity 70-90% and specificity 90-100% • How can we use the Centor criteria to aid in who should be tested? • 1 Centor criteria: 7% • 2: 21% • 3: 38% • 4: 57%
- 7. Be suspicious… • Suddenonset sore throat • Fever • Tonsillopharyngeal and/or uvular edema • Patchy tonsillar exudates • Cervical lymphadenitis • Scarlatiniform rash, strawberry tongue • Hx of GAS
- 8. With 3 ormore Centor criteria: • Rapid antigen detection test (RADT) • NO reflex culture • Get a good sample, and do it before ANY abx • If RADT +: PCN V x 10 days; consider azithromycin in the PCN allergic pt • Treat to reduce symptoms, transmission, and complications • Severity of presentation does not portend likelihood of complications
- 9. GAS: 5-15% • (+)Sudden onset sore throat, tonsillar exudate, TENDER cervical adenitis, fever • (-) (Usually) cough, rhinorrhea • Identification and treatment reduces risks of complications • Suppurative complications: • Tonsillopharyngeal cellulitis or abscess • Otitis media • Sinusitis • Nec fasciitis • Strep bacteremia • Meningitis • Jug vein septic thrombophebitis • Nonsuppurative complications: • ARF: 2-3 weeks after pharyngitis; arthritis, carditis, chorea, subQ nodules, EM • Recent increase in US • Scarlet Fever: delayed-type skin reaction to pyrogenic endotoxin (do rapid strep testing and throat culture) • Strep TSS • Acute glomerulonephritis
- 10. 30 year oldintern presents with a sore throat • No fever • Purulent cough • No LAD • What is this NOT? • What should you NOT do? • What causes the majority of pharyngitis? • 60% of patients with sore throats get abx, azithro>>PCN
- 11. Memorable Example • 60F w/ MMP presented to PCP with sore throat (1 Centor criteria) • Empiric azithromycin no response • Empiric ceftriaxone/azithromycin no response • Empiric Ciprofloxacin no response • Ultimate clinical improvement…BUT • Develops diarrhea; C diff toxic positive • Delay in initiation of treatment • Develops toxic megacolin • PEA arrests on feculent material, expires
- 12. 30 year oldintern presents with sore throat • No fever, LAD, tonsillar exudate • Recent sexual activity • What 4 diagnoses should you consider?
- 13. 30 year oldintern presents with sore throat • Persistent dry cough • Otherwise, young, healthy person • Feeling awful • What diagnoses to consider?
- 14. 30 year oldpatient presents with sore throat • Low grade fever • Muffled voice • Malaise • On exam, lesion in the back of the mouth that bleeds when you poke it • What follow up history do you want from the patient?
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- 16. Non-GAS Pharyngitis • Causes(I): • Viral (50%): influenza, parainfluenza, coronavirus, rhinovirus, adenovirus, enterovirus RSV, metapneumovirus, coxsackie • Strep/viral coinfection • Influenza: cough, myalgias, hyperemia, NO (unlikely) tonsillar exudates • EBV: malaise, HA, low grade fever, tonsillitis, pharyngitis, cervical LAD, high fevers (diffuse adenitis, splenomegaly, skin rash less likely) • Primary HIV: mononucleosis-like syndrome +/or aseptic meningitis • HSV: pharyngitis and/or tonsillitis (up to 10% of cases in college students). Pharyngeal edema, tonsillar exudate, oral exudate, ulcerative lesion. • Non-group A strep (clinically indistinguishable from strep)(15%) (group C and G) (throat culture)
- 17. Non-GAS Pharyngitis –Causes (II) • Less common bacterial pathogens (<5%) • Diptheria: pharyngitis, malaise, low-grade fever; gray membrane that bleeds; consider in pts from other countries (lack of vaccine) • N. gonorrhaeae: rare (but common in higher risk groups; consider for college students, sexually active MSM, some HIV+ patients) • C. pneumoniae: pharyngitis + bronchitis/pneumonitis; • M. pneumoniae: young, healthy adult; pharyngitis, persistent cough, constitutional symptoms • No pathogen isolated (30%)
- 18. Pharyngitis Workup: Emphasis onDx Treatable Conditions • If >2 Centor criteria: • RADT with reflex throat cx for (+) RADT only • Consider throat cx if RADT (-) ONLY in: poorly controlled DM, immunocompromised • Influenza PCR • Consider: assessment for HIV, HSV, n. gonorrheae • Rule out: dangerous conditions
- 19. Pharyngitis: Exclude dangerousconditions • Epiglottitis: sore throat, odynophagia, muffled voice, fevers, stridor, hoarseness. Severity of sore throat >>>>OP exam • Peritonsillar abscess: unilateral sore throat, hot potato/muffled voice. Pooling of saliva. Trismus (66%) • Submandibular space infections: (Ludwigs): No trismus. Tender woody induration, sometimes crepitus, no LAD • Retropharyngeal space infections: often penetrating trauma **Imaging, early intervention
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