sore throat Flashcards
Case:
Our patient is D.P., a 3yr /M from San Andres, Manila who was
brought to the ER due to fever and drooling.
History of Present Illness
5 days prior to consult, the patient had colds with no associated
fever. No consult was done.
2 days prior to consult, the patient now had fever with Tmax 39,
anorexia and irritability.
1 day prior to consult, the patient’s fever persisted. It was now
associated with sore throat and drooling, prompting consult at the
ER today.
Ancillary History
Past Medical History: No previous hospitalizations or surgery, (-)
no history of asthma
Family Medical History: (-) Family history of bronchial asthma or
malignancy, (-) family history of DM and hypertension
Birth and Maternal History: Born FT to an 29 year old primigravid,
with no fetomaternal complications.
Immunization history: given BCG x 1 dose, OPV x 3 doses,
Hepatitis B x 2 doses, DPT x 3 doses , measles x 1 dose c/o the
local health center. No other immunizations were given.
Nutritional History: breastfed for 5 months , non-picky eater
Developmental History: sits without support at 8 mo, walks with
support and one-word sentences at 1 yr old
Personal and Social History: Lives with extended family in a 2
room apartment
PHYSICAL EXAMINATION
General Survey
Awake, muffled voice , sitting forward, mouth open, neck
extended
Anthropometrics
Weight =14 kg, height =95 cm
Vital signs
BP 90/60 HR 110 bpm RR 40 bpm T 39 C O2 sats (room air) = 100%
Skin
No rash, no jaundice
Head and Neck
Pink conjunctivae, anicteric sclerae, (-) nasal congestion, (+)
cervical lymphadenopathies, (+) pain with turning of the neck, (+)
bulging of posterior pharyngeal wall
Chest and Lungs
Equal chest expansion, (-) retractions, (-)rales, (-) wheezes, (+)
stridor
Cardiac
Adynamic precordium, distinct heart sounds, tachycardic, regular
rhythm, no murmurs
Abdomen
Normoactive bowel sounds, (-) tenderness, (-) guarding or
rebound tenderness, (-) hepatomegaly, intact Traube’s space
Extremities
Full and equal pulses, (-) edema/cyanosis/clubbing, CRT less than
2 sec
LABORATORY RESULT:
CBC
Date Normal
WBC 11 x109/L
RBC 3.1x109/L
Hgb 110 g/L
Hct 0.38%
MCV 85fL
MCH 25 pg
Platelets 350x109/L
Neut% 0.85
Lymph% 0.15
Mono% 0.0
Eo% 0.0
Baso% 0.0
Head CT scan (with contrast): central lucency, ring enhancement
and scalloping of the walls of lymph node
Lateral neck soft tissue xray: increased width in the
retropharyngeal space
Chest xray: N
Laryngoscopy: Abscess formation in deep cervical fascia
What are the different causes of sore throat?
ID: Pharyngitis, Peritonsillar abscess,
Retropharyngeal abscess, Infectious
mononucleosis, Epiglottitis, herpangina,
COVID, HFMD, Diphtheria
Non-ID: esophagitis (hot food/drinks),
GERD
What is the pathophysiology of acute pharyngitis?
secondary to infectious or non-infectious causes
(smoking, air pollutants, hot food)
- Virus: influenza, parainfluenza, adenovirus, rhinovirus,
RSV, coronavirus, enterovirus, EBV, etc
- Bacteria: GABHS, mycoplasma, Chlamydia
pneumoniae, Fusobacterium necrophorum, Chlamydia
trachomatis
- With infectious pharyngitis, bacteria/ viruses may
directly invade the pharyngeal mucosa, causing a local
inflammatory response.
- Rhinovirus and coronavirus can cause irritation of the
pharyngeal mucosa secondary to nasal secretions
what is the most common bacterial pathogen in acute pharyngitis?
Group A beta-hemolytic Steptococcus (GABHS/GAS)/Steptococcus
pyogenes
What is the virulence factor?
Produce exotoxin A, B, or C. M protein is an important
GAS virulence factor that facilitates resistance to
phagocytosis
What are the clinical manifestations of acute pharyngitis?
Viral:
1. Gradual onset
2. Moderate throat pain
3. Sx of viral URTI (conjunctivitis, coryza, cough)
4. Contacts with cold sx
5. Vesicles and ulcers (HSV)
6. Conjunctivitis (adenovirus)
Bacterial (GABHS):
1. Rapid onset significant sore throat
2. Fever >38C
3. Headache
4. Nausea/vomiting, abdominal pain
5. No URTI sx
6. red, enlarged tonsils with exudate, strawberry tongue,
palatal petechiae
7. Cervical LNE – swollen, tender, anterior cervical LN
8. Scarlatiniform rash – fine, red, popular, “sandpaper”
rash of scarlet fever. It begins from the face then
becomes generalized. Cheeks are red and area around
the mouth is more pale (circumoral pallor-like). Rash
blanches with pressure. More intense in the skin
creases, esp antecubital fossae, axillae, inguinal
creases (Pastia’s lines/Pastia’s sign)
§ (+)tourniquet test/ Rumpel-Leeds
phenomenon – capillary fragility can cause
petechiae distal to a tourniquet or
constriction from clothing
- Diarrhea, cough/colds, hoarseness, conjunctivitis are
NOT GAS, likely viral.
What is Pastia’s lines?
(+)tourniquet test/ Rumpel-Leeds
phenomenon – capillary fragility can cause
petechiae distal to a tourniquet or
constriction from clothing
How do we diagnose acute pharnyngitis?
- to detect GAS infection
1. throat C/S – gold standard for GABHS
2. Rapid antigen detection test (RADT) – for GABHS - Not readily available locally
- > 95% specificity, less sn: (+) no TC/S, (-) do TC/S
3. Streptozyme (+) - measures 5 Ab including anti-
What is the gold standard in the diagnosis of acute pharyngitis?
Throat C/S
What is the treatment for acute pharyngitis?
Antipyretic – Paracetamol, Ibuprofen for fever and pain
2. Lozenges, anesthetic sprays
3. Antibiotics (GABHS)
- 1st line: Penicillin V 25-50 mkd po q6 x 10 d:
- 2nd line: Amoxicillin 50mg/kg q6 x 10d
If with penicillin allergy: macrolide
Erythromycin 40mkd po q6h x 10d
Clarithromycin 15mkd q12 x 10d
Azithromycin 12mkd po x 5d
Clindamycin 20-30 mkd po q8h
- Recurrent:
1st line: Penicillin V or Amoxicillin
2nd line: Cefuroxime 20mkd po q12 or Co-amoxiclav 20-
40 mkd q8 x 10d
4. Tonsillectomy
- For recurrent streptococcal pharyngitis
- Paradise criteria:
(+) TCS, severe and frequent
>7 episodes in the previous year
>5 episodes in each of the preceding 2
years
>3 episodes in each of the preceding 3
years
What are the complications of GABHS
- Rheumatic fever
- Post-streptococcal GN
- Peritonsillar/retropharyngeal abscess
What is peritonsillar abscess?
- “Quinsy”
- Most common deep-space head and neck infection in
adults and children
What is the pathogenesis of peritonsillar abscess?
Bacterial invasion through the capsule of the tonsils
- Usually adolescents, >12yo
- GABHS and mixed anaerobes, S.viridans (mixed flora)
- Onset: follows as a complication of acute tonsillitis
What are the clinical manifestations of peritonsillar abscess?
- Recent hx of ATP that becomes more severe, gradual
onset - Fever, sore throat, dysphagia, odynophagia, drooling,
trismus - Asymmetric tonsillar bulge with displaced uvula –
diagnostic PE finding
what is the diagnostic PE finding in peritonsillar abscess?
Asymmetric tonsillar bulge with displaced uvula
