​Kembara Xtra - Medicine - Pharyngitis

​Kembara Xtra - Medicine - Pharyngitis 
Tonsillitis, a sore throat, and "strep throat" are some synonyms.
 Acute or ongoing inflammation of the throat's underlying tissues and pharyngeal mucosa
A Group Retropharyngeal or peritonsillar abscess are two suppurative and nonsuppurative consequences of streptococcus (GAS) pharyngitis that can be avoided.

Epidemiology 
One to two percent of all outpatient visits and six percent of all pediatric visits to primary care doctors are related to the 15 million cases that are diagnosed each year.
 The majority of cases (40–60%) are viral
GAS accounts for 15–30% of pediatric and 5- 15% of adult cases of acute pharyngitis, making it the most frequent bacterial cause. The incubation time is between 24 and 72 hours. Although it is a dangerous complication, there are only about 1 case of rheumatic fever per 100,000 people in the US. Early use of antibiotics has reduced occurrence.
Acute rheumatic fever affects people of all ages, while some etiologies and sequelae are more common in certain age groups. Group A -hemolytic streptococcal infection requires the treatment of between 3,000 and 4,000 individuals in order to prevent one episode of acute rheumatic fever.
Child Safety Considerations
Rheumatic fever is most common in children aged 5 to 18 and is a rare complication of streptococcal pharyngitis.

Pathophysiology and Etiology 
Acute viral illnesses that cause low-grade fevers include rhinitis, adenitis, parainfluenza, coxsackievirus, coronavirus, echovirus, Herpes simplex virus (HSV), vesicular lesions, Epstein-Barr virus (EBV), mononucleosis, cytomegalovirus (CMV), and HIV.
 Bacterial, acute (linked to increased fevers)
Neisseria gonorrhoeae, Corynebacterium diphtheriae (diphtheria), Moraxella catarrhalis, Chlamydia pneumonia, Fusobacterium necrophorum (20% cases in young adults), Group C or G Streptococcus, Mycoplasma pneumoniae, Francisella tularensis (tularemia), and Haemophilus influenzae are examples of group A -
Acute, non-infectious; caused by various mechanical, caustic, or trauma-related factors, including endotracheal intubation
Chemical irritation that is chronic and more likely not infectious (GERD)
- Radiation alterations - Vasculitis - Neoplasms - Smoking
Genetics
A group A -hemolytic streptococcal infection that goes untreated increases the risk of rheumatic sequelae in patients with a family history of rheumatic fever.

Risk factors include: rheumatic fever is possible, especially in children and adolescents between the ages of 5 and 15, age, cold and flu season (late fall through early spring), close contact with infected people (at home, in daycare, or in military barracks), immunosuppression, smoking, secondhand smoke exposure, acid reflux, oral sex, diabetes mellitus, recent illness (secondary postviral bacterial infection), and chronic ba colonization.

Prevention 
Refrain from coming into close touch with sick people.
Wash your hands often.
Avoid being around people who are smoking.
 Control avoidable causes, such as GERD.

Diagnosis Sore throat Hoarseness; "hot potato" voice Difficulty swallowing (dysphagia) or pain when swallowing (odynophagia) Cough (rare with GAS pharyngitis
Fever, Anorexia, Chills, Malaise, Fatigue, Headache, Dysuria, and Arthralgias (Suggest Gonococcal Etiology), as well as confirmed diagnoses or sick contacts with comparable symptoms


clinical assessment 
Exudate on or around enlarged tonsils
 Palatal petechiae with pharyngeal erythema
 Unilateral tonsillar enlargement (often known as a "frog's belly") or uvular deviation (possible peritonsillar abscess)
 Drooling, stridor, and trismus (possible peritonsillar or retropharyngeal abscess)
Cervical adenopathy (posterior most frequently associated with viral mononucleosis, anterior suggestive of GAS)
Fever (more common with bacterial illnesses)
 Pharyngeal ulcers (HIV, Crohn's disease, CMV, and other autoimmune vasculitides)
Punctate erythematous macules with reddish flexor creases and circumoral pallor imply streptococcal pharyngitis in the scarlet fever rash.
Hepatosplenomegaly and tonsillar/soft palate petechiae point to infectious mononucleosis (EBV/CMV).
Gray oral pseudomembrane is suggestive of infectious mononucleosis (EBV/CMV) and occasionally diphtheria.
 Erythematous-based transparent vesicles with characteristic features point to HSV or coxsackie A virus infection (herpangina).
Adenovirus is suggested by conjunctivitis.


Differential diagnosis: Allergic rhinitis/postnasal drip, viral infection, streptococcal infection, and GERD
Malignancy (squamous cell cancer or lymphoma)
 Irritants and chemicals (ingestion of detergent and caustics)
Oral candidiasis (Patients often complain mostly of dysphagia) Atypical bacterial (e.g., gonococcal, chlamydial, syphilis, pertussis, diphtheria)
Thyroiditis (which may or may not be painful and may be related to hyperthyroid condition)
 Epiglottitis, which is characterized by stridor, drooling, and progressive respiratory distress.


Investigations in a laboratory 

The requirement for additional testing is determined by prediction rules (see below).
Avoid testing for GAS pharyngitis in children under the age of three because acute rheumatic flares are uncommon, unless there is a close sick contact who is GAS-positive. Additional testing is typically not required if viral-like clinical features (e.g., cough, rhinorrhea, hoarseness, oral ulcers, diarrhea, conjunctivitis, rash) are present.
The modified For group A streptococcal infection, use the Centor clinical prediction rule:
tonsillar exudates, tender anterior chain cervical adenopathy, and a lack of cough all receive points.
Fever by history, plus one point; age under 15, plus zero points; and age between 15 and 45, minus one point;
 Scoring: If 4 points, there is an empirical treatment and a positive predictive value of 80%.
- If 2 to 3 points, fast strep antigen has a positive predictive value of less than 50%; treat if GAS-positive.
- If 0 or 1, the positive predictive value is less than 20%; do not test; instead, treat the symptoms and follow up as necessary.
Initial examinations (lab, imaging)
If testing is done, it is typically for GAS. Options consist of:
Rapid antigen streptococcus test (RAST), which is a rapid supplement to throat culture and has an 86% sensitivity and 96% specificity (however sensitivity varies on modality kit)
- Gold standard—90–95% sensitivity; blood agar throat culture from swab Adults with negative RAST do not require backup throat cultures. Due to the increased risk of problems, they are advised for kids with negative RAST, but if a highly sensitive immunoassay or molecular test was done, they can be skipped.
- Antistreptolysin O (suspect carrier state if culture is positive and ASO titers remain stable)
If history points to a different diagnosis, special tests may be necessary.
- Viral cultures for HSV - Warm Thayer-Martin plate or antigen testing for N. gonorrhoeae - Monospot for EBV
- CMV IgM serology
Tests in the Future & Special Considerations
Recurring GAS infections may be a sign that the host is producing -lactamases and may call for an antibiotic with anti--lactamase activity.
Bacitracin disk sensitivity of hemolytic colonies implies group A -hemolytic streptococcus in the test interpretation.

Management 

Symptomatic alleviation is the main goal of treatment, unless bacterial infection is proven or strongly suspected.

General Actions 

When bacterial etiology is not suspected, conservative therapy is advised:
Gargles with salt water
Acetaminophen 10 to 15 mg/kg/dose q4h PRN (pediatric) for discomfort or fever. Do not exceed >3 g/day in adults.
NSAIDs (non-steroidal anti-inflammatory medicines) are more effective than acetaminophen in treating GAS pharyngitis discomfort or fever.
 Pain reliever lozenges
Humidifier with cool mist
 Viscous lidocaine (2%) Hydration (PO or IV if PO is not tolerated) swish/spit 5 to 10 mL PO every four hours (severe pain)
Child Safety Considerations
Opioids are not advised because of the black box warnings
Aspirin should not be used to treat symptoms in young patients due to the possibility of Reye syndrome. Lower threshold for starting antibiotics due to higher risk of rheumatic fever.

Medication: The main purpose of antibiotics, especially penicillin, is to avoid problems.
- 60–70% of children with pharyngitis who visit their primary care provider receive antibiotic prescriptions (4). Antibiotic use increases as a result of empiric therapy.
- A typical course of treatment lasts 10 days.
- The risk of poststreptococcal glomerulonephritis is not decreased by antibiotics.
- The time that symptoms last is reduced with antibiotics by about 16 hours.
By day 3 (NNT 4 if GAS-positive, 6.5 if GAS-negative, and 14.4 if untested), antibiotics may prevent pharyngitis/fever.
 Systemic or intralesional injectable steroids are typically required for ulcers caused by autoimmune disorders.
HIV-related ulcers are brought on by dropping CD4 counts and react to rising CD4 titers in individuals.
When used with antibiotics, corticosteroids may shorten the symptom's 24-hour duration by a minor amount. Currently, routine use is not advised.


Initial Line
suggested first-line treatments:
Children (27 kg) should take 250 mg PO TID of penicillin V (BID dose is acceptable if there is good compliance); adolescents and adults (>27 kg) should take 250 mg PO QID or 500 mg PO BID.
Penicillin G benzathine: 600,000 units IM 1 dosage for children under 60 lb (27 kg); 1.2 million units IM 1 dose for children above 60 lb and adults.
Amoxicillin: 50 mg/kg orally once day (maximum dose: 1,000 mg) or 25 mg/kg orally twice daily (maximum dose: 500 mg)
ALERT
If the diagnosis is uncertain, use with caution as amoxicillin use with EBV infection can result in rash.

Next Line

When type IV hypersensitivity occurs without a prior history of anaphylactic penicillin allergy:
- Cephalexin 20 mg/kg PO BID, 25 to 50 mg/kg/day split BID for children, or 1,000 mg PO QID for adults (maximum of 4 g/day).
- Cefadroxil 30 mg/kg PO once daily, with a daily maximum of 1 g.
If you have a history of type I hypersensitivity or anaphylactic penicillin allergy:
- Azithromycin (12 mg/kg, orally, once daily for 5 days; maximum dose: 500 mg)
- Clarithromycin, 250 to 500 mg PO BID for adults, or 7.5 mg/kg PO BID (maximum = 250 mg/dose) for children.
- Clindamycin 7 mg/kg PO TID (maximum dose of 300 mg), or (for children) 10 to 30 mg/kg/day PO divided TID-QID, or (for adults) 150 to 450 mg PO TID-QID
When treating streptococcal pharyngitis, cephalosporins have a lower rate of antimicrobial failure than penicillin, which is most frequently employed to prevent rheumatic sequelae.
Newer macrolides are more expensive and have a questionable track record when it comes to preventing rheumatic problems, but they are effective against streptococcal pharyngitis.
Macrolide-resistant GAS strains are currently 10% more common worldwide than they are in the United States.


Problems to Refer 

 Tonsillectomy is advised for patients who have experienced seven or more throat infections (viral or bacterial) in one year, five or more infections per year for the past two years, or three or more infections per year for the previous three years. Document each GAS-confirmed episode to support the need for future tonsillectomy and adenoidectomy.
Patients who are challenging to treat medically, such as those who are allergic to several antibiotics, might consider having their tonsils removed.

Patients are often no longer contagious after 24 hours of antibiotic treatment, thus it is important to finish the entire course of antibiotic therapy regardless of how their symptoms respond.
The culture of follow-up for GAS is not advised.


diet
​Tolerable. Encourage them to drink more water.

The symptoms of streptococcal pharyngitis will cure on their own without treatment, but rheumatic consequences are still possible. Streptococcal pharyngitis runs a 5- to 7-day course with a peak temperature at 2 to 3 days.


Complications 
 Poststreptococcal glomerulonephritis Peritonsillar abscess (also known as quinsy tonsillitis): regarded a clinical diagnosis and does not require ultrasonography or computed tomography. Rheumatic fever (e.g., carditis, valve disease, arthritis). usually call for transoral/percutaneous drainage. Quinsy (acute) tonsillectomy is another possible procedure. The majority of sources advise treating the acute infection before surgery.
With nasal trumpets, acute airway compromise (rare) may usually be avoided. Consult an otolaryngologist or an anesthesiologist.
● In a chronic pharyngeal GAS carrier, recurring viral infections may be the cause of repeated GAS pharyngitis episodes. A known chronic pharyngeal GAS carrier should avoid repeated diagnostic procedures and antibiotic treatment because they are rarely contagious and rarely face major risks.

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