Pharyngitis: Goldstein

A patient with conjunctivitis in the setting of acute pharyngitis most likely has a viral or bacterial infection?

Conjunctivitis is a hallmark of viral pharyngitis and is most commonly caused by Adenovirus. Conjunctivitis is not always present.

The majority of Epiglottitis cases effect what age range of individuals?

90 to 95% of Epiglottitiscases occur in patients 45 to 64 years old and those >85 years old.

What are the key physical findings that differentiate bacterial versus viral pharyngitis?

Bacterial Pharyngitis presents suddenly with high grade fever (>100), petechia or white exudates causing sever inflammation of the throat and tonsils. Viral Pharyngitis typically has a gradual onset with mild fever, conjunctivitis, and rhinitis. Pharynx will be erythematous with exudate in most cases.

How can you tell the difference between bacterial and viral pharyngitis based on palpation of lymph nodes and which lymph nodes should be inspected?

Bacterial pharyngitis causes the lymph nodes of the anterior cervical chain to become large and tender secondary to the adaptive immune response. Viral pharyngitis may or may not cause lymph nodes to swell. In the even that lymph nodes do swell, they are much smaller than those found in bacterial pharyngitis.

If Centor Criteria is used to diagnose adults with GAS pharyngitis, what is used to diagnose children and how do these criteria differ?

CDC recommendations are used for diagnosis of GAS pharyngitis in children. Children with a sore throat must have two or more of the following to be diagnosed: Tonsillar Swelling or Exudates. Tender & Swollen anterior cervical chain nodes. Under age of 15. CDC differs from Centor primarily in that CDC requires a microbe culture even if the Rapid Strep Test is negative whereas Centor criteria does not require it.

What is the Centor Criteria used for, what patient population does it apply to, and what criteria must be met in order for a positive diagnosis?

Centor Criteria is used to diagnose adults with Group A Strep pharyngitis. In the setting of an adult with a sore throat, Centor Criteria dianosis requires two or more of: Fever > 100 degrees F. Tonsillar Swelling or Exudate. Cervical Lymphadenopathy. Absence of Cough.

Do the following criteria fall under Centor Criteria or CDC recommendations for diagnosing GAS Pharyngitis? Fever > 38 celcius. Tonsil swelling or exudate. Cervical Lymphadenopathy. Absence of Cough. No requirement for culture in the event of a negative Rapid Strep Test.

Centor Criteria. Fever and the lack of requirement for a culture in the event of a negative Rapid Strep Test are key differences between CDC and Centor criteria.

What is the most common cause of Epiglottitis and what type of clearance will it demonstrate on Blood Agar and why?

Haemophilus influenza type B is the most common cause of Epiglottitis. H. Influenza B is unable to lyse RBCs and cannot grow on Blood Agar unless there is another organism that can lyse the RBC or addition of Factor 5. HiB readily grows on chocolate agar as these RBCs have been lysed via heat prior to innoculation.

What is Jones Criteria used for and what is needed in order to make a positive diagnosis?

Jones Criteria is used to diagnose Rheumatic Fever. In the setting of a recent Strep infection the Jones Criteria requires 2 major or 1 major and 2 minor criteria to make a positive diagnosis. Major Criteria: (J) Poly Arthralgia. (O) Pancarditis. (N) Nodules. (E) Erythema Marginatum. (S) Sydenham's Chorea. Minor Criteria: Fever. Elevated ESR. Arthralgia. Long PR interval.

What viral infection of the throat is most often confused with GAS pharyngitis, why is it so easily confused, and how will these patients present upon follow-up after antibiotic treatment with amoxicillin?

Mononucleosis caused by Epstein Barr Virus (HHV-4) and is most often confused with GAS Pharyngitis. EBV presents with high grade fever, and severe inflammation and exudates in the oropharynx which is nearly identical to how bacterial pharyngitis presents. Amoxicillin given to EBV patients will cause a global erythymatous rash, which is the typical drug reaction in the setting of Mononucleosis. (Typically, viral pharyngitis does not present with fever and demonstrates mild rather than severe inflammation of the throat)

What are the most common causes of viral pharyngitis?

Most common causes of viral pharyngitis are: Adenovirus. Rhinovirus. Coronavirus. Cosackievirus (A). Influenza. Herpes. (OH CrAP: Orthomyxo, Herpes, Corona, Adeno, Picorna)

Why is it vital to provide empirical treatment for Group A Strep infections even in the setting of a negative Rapid Strep Test?

Rapid Strep Tests are 70 to 90% sensitive in detecting GAS and false negatives are possible. GAS infecting mucuous membranes posses M-protein which is a molecular mimic of protein moieties found on heart valves. Delay in the treatment of GAS pharyngitis will increase the risk of the patient developing Rheumatic Fever which can lead to Rheumatic Heart Disease.

What patient demographic, based on age and sex, is most at risk for developing Rheumatic Fever and what criteria is used to diagnose RF?

Rheumatic Fever is most commonly found in individuals between 5 and 17 years old with Females being effected more than males. Rheumatic Fever is diagnosed using the JONES criteria. Joints: Migratory Arthralgia. O Nodules: Subcutaneous. Erythema Marginatum. Syndenham Chorea.

What is the most dangerous long term complication of GAS Pharyngitis, what structures are typically involved, and how can this be prevented?

Rheumatic Fever is the most dangerous complication of GAS Pharyngitis. Rheumatic fever is caused by the immune response to GAS M-protein which shares moieties with proteins found on the heart valves, Thus antibodies against the bacteria also damage the heart valves. Rheumatic fever is prevented by providing antibiotics, beta-lactams or macrolides, to the patient within 2 weeks of the onset of symptoms.

How long post infection does Rheumatic Fever present and how does this compare to Post Streptococcal Glomerulonephritis?

Rheumatic Fever typically presents 2 to 4 weeks post infection. Post Streptococcal Glomerulonephritis presents 10 to 14 days post infection. (Dr. Goldsteens' slide states that RF occurs 10 to 14 days post infection. This is a mistake. All other resources checked confrim the 2 to 4 week timeline)

True or False. Pharyngitis is most commonly caused by a virus rather than a bacteria.

True.

True or False. Bacterial pharyngitis is not associated with coughing while viral pharyngitis is associated with coughing, but is variable.

True. Viral pharyngitis can cause coughing where as bacterial pharyngitis does not.

In terms of patient age demographics and seasonal timing, how do bacterial and viral pharyngitis compare?

Viral pharyngitis typically effects the middle age adults and the very young (<4 or >45) and can occur anytime of the year. Bacterial pharyngitis typically effects children and adolecents between 5 and 15 years old. Bacterial pharyngitis is most common in winter and early spring.