Pharyngitis


Bacterial

Background

  • General term for inflammation of the pharynx
  • Very common reason for ED visits
  • Can be viral (40%) or bacterial (30%) in origin
    • No pathogen isolated in 30% of cases
  • Most cases < 2 years old are viral
  • Important to distinguish from Abscess
    • Trismus, deviated uvula (peritonsillar abscess)
    • Drooling, fever (retropharyngeal abscess)
    • Lateral XR can help distinguish

Etiologies

  • Group A beta-hemolytic strep (GABHS)
    • Most common single cause of pharyngitis
      • 15-30% in children; 5-10% adults
    • Incidence highest in winter, early spring
    • Untreated patients infectious
      • During acute phase
      • For 1 week after
  • N. gonorrhea
  • Corynebacterium diphtheriae
    • Thick gray membrane, difficult to remove
  • Moraxella (Branhamella) catarrhalis
  • Group C and G streptococci (rare)
  • Kawasaki Disease
  • Mycoplasma
  • Chlamydia
    • Fever, cough, sore throat
  • Fungal: Candida (esp. w/immunocompromised)

Symptoms

  • Sore throat
  • Anorexia, abdominal pain
  • Fever, chills
  • Malaise
  • Headache
     

Physical Exam

  • Sneezing, cough, rhinorrhea
    • Usual with viral pharyngitis
  • Pharyngeal erythema
  • Enlarged tonsils
  • Tonsillar exudates
  • Soft palate petechiae
  • Cervical lymphadenopathy
  • Rash
    • Scarlet fever rash ("sandpaper" rash)
      • Punctate erythematous macules
      • Reddened flexor creases
      • Circumoral pallor
    • Papulovesicular lesions
      • Herpangina (usually coxsackievirus A)
    • Conjunctivitis
      • Common with adenovirus infections
  • For Step. pharyngitis: (GABHS)
    • Exposure in past 2wks: 91% spec.
    • Sudden sore throat, odynophagia
    • Fever, headache, abd pain, nausea, vomiting
      • Low risk: coryza, cough, hoarseness, no fever, no erythema
    • PE
      • Erythema/exudate
        • petechiae on soft palate (95% spec)
        • beefy red uvula
      • Anterior lymphadenopathy
      • Scarlet fever "sand paper" rash
        • Uncharacteristic: conjunctivitis, stomatitis, ulcerative lesions
      • Search for Signs of dehydration, murmur (RF)

Diagnostic testing

  • Can't distinguish b/w those w/viral pharyngitis who are strep carriers and those w/strep pharyngitis
  • Rapid strep test
    • Cost-effective when followed up with throat culture
  • Throat culture: gold standard (90-99% sens)
    • Can w/hold therapy until culture back if unsure of diagnosis
    • Delay does not increase risk of rheumatic fever
    • Low incidence in adults, min risk of RF: can wait for tx in adults
  • Monospot test if suspect mononucleosis

Treatment

  1. Goals
    • Prevent complications
      • Abscess
      • Mastoiditis
      • OM
    • Prevent rheumatic fever
    • Decr communicability, hasten improvement
  2. Symptoms usually resolve w/in 3-4d even w/o tx
  3. Treatment does not prevent glomerulonephritis development
    • Early treatment (within 48 hrs)
      • Shortens duration of symptoms
      • Limits spread to others
      • Saves time
      • May lead to higher failure rate
  4. General supportive care
    • Rest, oral fluids, salt-water gargling (soothes throat)
    • Anesthetic gargles and lozenges
      • Those containing benzocaine are best
    • Acetaminophen
    • NO NSAIDS or ASA (Reyes' synd)
    • OTC cough suppressants
      • No effect
  5. Medications
    • Penicillin (treatment of choice)
      • 25-50 mg/kg/d PO div. q6hr x10d
      • 250 mg QID/ 500mg BID x 10d (adult)
    • Amoxicillin 1500 mg PO qd (750 mg if Body wt <30 kg) is equally effective
    • Erythromycin
      • 30-50mg/kg PO per day div BID, QID x10d (max 1g/d)
      • 500mg PO QID x10d (adult)
    • Azithromycin
      • 12 mg/kg PO qD x5d
      • 500 mg PO x1 then 250mg PO qd x4d (adult)
  6. Severe/refractory disease
    • Clindamycin
      • 20-30mg/kg/d PO div. QID max: 300/dose
      • 300mg PO QID x10d (adult)
    • Amoxicillin/clavulanate
      • 40-45 mg/kg/d (amoxicillin) PO div. BID-TID
      • 500/125 mg PO TID x 10d (adult)

Disposition

  1. Admit
    • Any severe dehydration, airway compromise, abscess
    • Mononucleosis w/: airway compromise, severe hepatitis, Guillain-Barre, inability to swallow, splenic rupture
    • Diphtheria: all cases for cardiac monitoring, respiratory isolation
      • May be reportable to public health
  2. Discharge
    • Most cases w/symptomatic relief: rest, fluids, pain control
      • Avoid aspirin/NSAIDs in children (Reyes')
    • ENT referral for tonsillectomy if sever / recurrent infection

 

Viral

Pathophysiology

  • Inflammation of the tonsils/pharynx
  • Most cases are viral
  • Can be caused by many agents

Diagnostic Testing

  • Usually unnecessary
    • Does not alter course or treatment
  • CBC
    • WBC count slightly elevated
    • NO bandemia
    • WBC count may go below 5000 in 4-7 days (50%)
    • May see atypical lymphocytosis
      • More common in mononucleosis, CMV infection, acute retroviral syndrome
  • Rapid strep screen and culture are NEG
  • Viral cultures generally NOT done
    • Rarely affect course, prognosis or treatment
    • May be obtained for research purposes