Pharyngitis w exudate

· Lemierre's syndrome

Patients typically present with a history of recent oral infection (pharyngitis) and have fevers, rigors, and neck pain and swelling. Lymphadenopathy may be present; a palpable venous cord may also be present. Patients with Lemierre's syndrome may have pulmonary symptoms related to septic emboli. They may develop multiple pulmonary abscesses (will have cough)

Group C and G Streptococcus

Pharyngitis caused by group C or G Streptococcus is clinically indistinguishable from GAS pharyngitis. Infection with group C or G streptococci most often occurs among college students and young adults and has been associated with community and foodborne outbreaks . In contrast with GAS pharyngitis, infection with group C or G streptococci has not been associated with acute rheumatic fever or other immune-mediated complications may not have symptoms

Bacterial: GABHS presentation

Pic: This patient with streptococcal pharyngitis has prominent bilateral tonsillar exudate without peritonsillar swelling, and scattered tonsillar petechiae. fever, pharyngeal edema, patchy tonsillar exudates, prominent, tender, anterior cervical lymphadenopathy · "Hot potato voice" N/V abdominal pain-often associated w fever

· Nonbacterial/Viral: Mono Epi

15- to 24-year age range

· Nonbacterial/Viral: Mono presentation

Classic Triad: -Fever -tonsillar pharyngitis -lymphadenopathy The syndrome is often heralded by malaise, headache, and low-grade fever before the development of these more specific signs (triad) Fatigue: THEY WILL BE VERY TIRED Hepatosplenomegaly (seen in 50 to 60 percent of patients with IM and usually begins to recede by the third week of the illness) --Splenomegaly-abdominal pain and or a falling hematocrit · Avoid contact activities 3-4 wks · Spontaneous splenic rupture Findings strongly supportive of IM Dx: Palatal petechiae, di, and posterior cervical adenopathy (classic)

Bacterial: C. Diptheriae Diagnosis

Definitive diagnosis of diphtheria requires culture of C. diphtheriae from respiratory tract secretions or cutaneous lesions and a positive toxin assay. Routine laboratory results are usually nonspecific and may include a moderately elevated white blood cell count and proteinuria.

GABHS and Scarlet Fever MOA

Erythematous eruption due to a toxin produced by beta-hemolytic streptococci Scarlet fever with pharyngitis can predispose to acute rheumatic fever.

Bacterial: GABHS MOA

GABHS bacteria transmitted via respiratory secretions · Incubation 24-72 hrs · If treated-no longer contagious after 16 hrs of starting anbx. Ok to return to school/work 24hr after · If untreated-continues to be contagious for up to 10 days after symptom resolution

Bacterial:Group A-beta hemolytic streptococci (GABHS) or (GAS) epidemiology

GAS is the most common bacterial cause of acute pharyngitis and is estimated to cause 5 to 15% of acute pharyngitis in adults Children > adults Peak season: Later winter, early spring

GABHS and Scarlet Fever epi

GAS pharyngitis is most common in school-age children but may occur in younger children, especially if they have contact with school-age childre

Bacterial: C. Diptheriae epi

Highest incidence: adolescents and young adults immunocompromised (find out if vaccinated)

Bacterial: GABHS testing

Not needed in everyone o If meet all criteria for strep, can treat empirically o If not culturing or not positive for strep: empiric (don't know what it is) -- Avoid macrolides for empiric therapy d/t F.necrophorum Centor scale: CENT-OR: Cough absent, Exudate, Nodes (ant cerv), Temp (fever), young (+1) OR old (-1) modifiers · Throat culture: gold standard o Takes a few days to get results (2 days) - Do you treat in meanwhile..how will decide? · If fit criteria for strep, and negative culture. Just treat. · Technique in obtaining sample: o Important in minimizing false negative o Rub/twirl over both tonsils or tonsillar fossae if removed § No tongue or cheek

· Nonbacterial/Viral: Mono time diagnosis

Should be suspected when an adolescent or young adult complains of sore throat, fever, and malaise and also has lymphadenopathy and pharyngitis on physical examination The presence of palatal petechiae, splenomegaly, and posterior cervical adenopathy are highly suggestive of IM, while the absence of cervical lymphadenopathy and fatigue make the diagnosis less likely o Rash reaction to PCNs o Labs-monospot § Lab done that same day (point of care lab) o Serum-10% or > atypical lymphocytes support dx § CBC

Bacterial: C. Diptheriae Time course

The onset of symptoms is typically gradual; the most common presenting symptoms are sore throat, malaise, cervical lymphadenopathy, and low-grade fever. The earliest pharyngeal finding is mild erythema, which can progress to isolated spots of gray and white exudate

Bacterial: GABHS time course

acute-onset sore throat,

Bacterial: F. Necrophorum MOA

an anaerobe that often colonizes the oropharynx, is a putative cause of pharyngitis. F. necrophorum has been detected in oropharynx of approximately 2 to 10 percent of asymptomatic young adults

Bacterial: C. Diptheriae MOA

infectious disease caused by the gram-positive bacillus Corynebacterium diphtheriae. Infection may lead to respiratory disease, cutaneous disease, or an asymptomatic carrier state. The word diphtheria comes from the Greek word for leather, which refers to the tough pharyngeal membrane that is the clinical hallmark of infectio

· Nonbacterial/Viral: Mono time course

sub acute can be months gradual onset

Bacterial: C. Diptheriae Presentation

§ "Bulls neck" appearance of soft tissue swelling of neck § Exudate forms a "pseudo-membrane" ("if wipe off will cause bleeding") § Similar to strep · Pharyngeal erythema & exudate · Fever · Cervical lymph

Bacterial: F. Necrophorum Time course

§ Distinguishing features: · Does not improve in usual time frame o GAS and viral improves in 3-5 days w/o Rx Fusobacterium necrophorum, a newly recognized bacterial cause of pharyngitis, can result in a potentially devastating suppurative complication called Lemierre syndrome, which usually begins with a sore throat that improves over the first four to five days.5 The patient then has a recurrence of symptoms, with the addition of bacteremic symptoms including rigors, fever, and night sweats. Patients also develop suppurative internal jugular thrombophlebitis and metastatic infections, especially in the lungs, joints, or brain. Patients with Lemierre syndrome have an estimated mortality of 5 percent, with significant short- and long-term morbidity.6

Why treat even though it resolves spontaneously?

§ Reduce contagiousness from 1-2 wks post infections down to 1 day after start antibiotics § Reduce sequellae: · Peritonsillar abscess · Acute rheumatic fever: NNT (number need to treat) 3,000-4,000 to prevent 1 case of rheumatic fever o Systemic disease affecting the peri-arteriolar connective tissue and can occur after an untreated group A streptococcal pharyngeal infection o Rheumatic heart disease-valve damage d/t rheumatic fever · Glomerulonephritus-post streptococcal; only certain strains o Children <7 yo most at risk o Up to 5-10% w strep pharyngitis, 25% skin strep o Controversial whether tx prevents

GABHS and Scarlet Fever presentation

§ fever, pharyngitis, THEN scarlatiniform rash: fine popular w rough texture..neck trunk-axillary,groin, extremities (fine sand paper feeling) § Desquamation (peeling) of axilla, groin, palms · Begins-7-10 days after rash resolution · May last up to 6 wks · Proportional to intensity of rash

Bacterial: F. Necrophorum Presentation

· Fever -tonsillar exudate · Anterior cervical adenopathy of the superior chain ("tonsillar lymph nodes") · Peritonsillar abscess · Neg strep (RADT & culture), neg mono spot

Bacterial: F. Necrophorum epi

· Late adolescents, early adults 15-25 yo

Why treat F. Necrophorum?

· Lemierre's syndrome o Septic thromboemboli from internal jugular d/t infection § Deep tissue neck abscess which penetrates carotid sheath o 1:400 pt w untreated F. necrophorum 10-15% mortality

· Nonbacterial/Viral: Mono MOA

· Spread via saliva o Long incubation 4-7 wks

GABHS and Scarlet Fever time course

·May last up to 6 wks