Physical findings can help guide diagnosis (Figure 1). Examination of patients who present with sore throat may reveal tonsillitis, tonsillopharyngitis, or nasopharyngitis. Before Pharyngitis ( sore throat) is a common upper respiratory infection that usually goes away after a few days. Randel A. AAO-HNS guidelines for tonsillectomy in children and adolescents. Major criteria include carditis, migratory polyarthritis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum. S. pyogenes are gram-positive cocci that grow in chains ( see figure 1 ). Gieseker KE, Roe MH, MacKenzie T, Todd JK. Tanz RR, Shulman ST, Barthel MJ, Willert C, Yogev R. Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci. Signs and symptoms of group A versus non-group A strep throat: a meta-analysis. Canadian guidelines on sexually transmitted infections. [ 1] The most common and important bacterial cause of pharyngitis is Streptococcus pyogenes (group A Streptococcus [GAS]). Zwart S, Rovers MM, de Melker RA, Hoes AW. The pharynx should be examined for erythema, hypertrophy, foreign body, exudates, masses, petechiae, and adenopathy. Alternatively, the FeverPAIN score (Figure 3) has gained popularity in the United Kingdom.19 It predicts strep throat based on acute symptom onset (< 3 days), recent (< 24 hours) fever, absence of cough or coryza, and purulent or inflamed tonsils. Careers, Unable to load your collection due to an error. Infectious causes range from generally benign viruses to GABHS. www.guideline.gov/summary/summary.aspx?doc_id=7324. This relies on accurate differentiation between bacterial and viral infections. On examination, the typical findings of acute pharyngitis may include an erythematous and swollen pharynx, tonsillar hypertrophy and inflammation (with or without tonsillar exudates), fever, edematous uvula, petechial rash along the palate, and tender anterior cervical lymphadenopathy. Acute inflammation of the tonsils and pharynx. Symptoms often manifest after an incubation period ranging from 1 to 5 days, and occur most commonly in the winter or early spring. Clinical management depends on the inciting cause of pharyngitis but ultimately can be separated into symptomatic and antimicrobial therapy. Scores can be further used to decide when antimicrobial therapy versus follow-up is warranted. For severe symptoms, viscous lidocaine preparations (e.g., Magic Mouthwash), stronger pain medicines or narcotics, or alternative modalities can be tried. She denies having a cough or runny nose but has been febrile with intermittent chills. In a patient with typical symptoms, no further testing is needed.32. The site is secure. She denies recent sick contacts and has not traveled in the past 2 months. They exhibit -hemolysis (complete hemolysis) when grown on blood agar plates. Penicillin for acute sore throat in children: randomized, double blind trial. She is hoping to obtain an antibiotic prescription to alleviate her symptoms. Traitement antimicrobien des infections ORL. Essential Infectious Disease Topics for Primary Care, Springer Nature - PMC COVID-19 Collection, www.cdc/gov/drugresistance/community/files/ads/Acute_Pharyngitis.pdf. FOIA These modalities are inexpensive, easy to use, and provide an appreciable degree of comfort relief. Quintana EC. Corticosteroids as standalone or add-on treatment for sore throat. La traduction en franais de cet article se trouve www.cfp.ca dans la table des matires du numro davril 2020 la page e119. Sandwich ELISA microarrays: generating reliable and reproducible assays for high-throughput screens. Differences in individual clinical routines will dictate whether empiric treatment is used for patients with three or four Centor Criteria, or if treatment is based on subsequent laboratory test results. All Rights Reserved. Depending on the season and the patient's age, 70% to 90% of acute episodes are viral and involve a wide array of common viruses (Table 33-1).By far, the most common virus associated with pharyngitis is the common cold agent, rhinovirus. Adapted from the National Institute for Health and Care Excellence.38, Traditionally, there has been a low threshold for treating pharyngitis owing to the risks of bacterial complications. Empirical antibiotic use should be limited to patients who are severely ill, have a high risk of complications, or show no signs of improvement within 5 days of presentation. Children with GABHS should be kept home from school until 24 hours after the initiation of antibiotic therapy. official website and that any information you provide is encrypted Kawasaki Disease, Sore Throat, Rheumatic Fever, Scarlet Fever, Throat Culture. However, clinical impression is only moderately accurate in diagnosing peritonsillar abscess (78 percent sensitivity and 50 percent specificity in one series of 14 patients).20 Intraoral ultrasound examination is an accurate diagnostic test if abscess is suspected. Ms Z.s lack of cough and rhinorrhea help to rule out sinusitis and postnasal drip. Etiologic agents are passed through person-to-person contact, most likely via droplets of nasal secretions or saliva. McIsaac WJ, Kellner JD, Aufricht P, et al. government site. The majority of cases are of viral origin and do not require antibiotic treatment. Pharyngitis is one of the most common conditions encountered by the family physician.15 The optimal approach for differentiating among various causes of pharyngitis requires a problem-focused history, a physical examination, and appropriate laboratory testing. The Centor Criteria is an effective clinical tool that may help guide this decision. Maintaining adequate hydration is critical, regardless of treatment strategy. Minimize the risk of developing rheumatic fever and suppurative complications. This chapter reviews the most common causes of pharyngitis, relevant available clinical information, appropriate laboratory tests, recommended treatment guidelines, possible complications, and general strategies for evaluating patients with acute pharyngitis. Diagnosing strep throat in the adult patient: do clinical criteria really suffice? When evaluating a patient with pharyngitis and outlining a treatment plan, the initial goals of sore throat management must be kept in mind: National Library of Medicine Sore throat is common and has substantial medical and societal costs. Merrill B, Kelsberg G, Jankowski TA, Danis P. What is the most effective diagnostic evaluation of streptococcal pharyngitis? Acute rheumatic fever (ARF), a serious late complication of GAS pharyngitis, can be prevented with antibiotic . Shaikh N, Swaminathan N, Hooper EG. Aside from influenza and new-onset HIV, the viral causes of pharyngitis only require supportive care and do not necessitate extensive testing. The incidence of bacterial pharyngitis is increased in temperate climates during winter and early spring.16 There is often a history of streptococcal throat infection (strep throat) within the past year. Streptococcus pharyngitis and pharyngeal carriage: a meta-analysis. Characteristic signs and symptoms include fever, bilateral nonpurulent conjunctivitis, anterior cervical node enlargement, erythematous oral mucosa, and an inflamed pharynx with a strawberry tongue. Other less common causes of pharyngitis include allergies, trauma, cancer, reflux, and certain toxins. Antibiotic stewardship and the low incidence of streptococcal pharyngitis complications suggest that treatments can be largely supportive. To provide family physicians with an updated approach to diagnosis and treatment of pharyngitis, detailing key symptoms, methods of investigation, and a summary of common causes. Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Objectives. All authors contributed to the interpretation of the literature and preparation of the manuscript for submission. Although a broad variety of differential diagnoses must be considered, ranging from infectious or inflammatory etiology to traumatic or neoplastic processes, the vast majority of these symptoms derive from either a viral or bacterial source. Return to contact sports following infectious mononucleosis: the role of serial ultrasonography. sharing sensitive information, make sure youre on a federal Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis. of 1 PATHOPHYSIOLOGY OF PHARYNGITIS BACTERIA VIRUS Invasion of mucosa Local Inflammation Irritation of mucosa by secretions Release of toxins and proteases M-protein fragments of GABHS and sarcolemma antigens of myocardium Antigen-antibodies complex in glomeruli Produce the Signs and Symptoms Younger Child Older Child Fever Fever may reach 40 Making the diagnosis of GABHS (or any differential diagnosis) is important in the prevention of rheumatic fever and/or other suppurative complications, hastening illness resolution, and preventing transmission. Chaudhary S, Bilinsky SA, Hennessy JL, Soler SM, Wallace SE, Schacht CM, et al. The differential diagnosis for sore throat symptoms is extensive. Patients will have an elevated antistreptolysin-O titer and erthrocyte sedimentation rate. These include Kawasaki disease, trauma or exertional irritation, neoplastic processes, abscess (such as Ludwig's angina, para-pharyngeal or retropharyngeal, and peritonsillar), thyroiditis, gastroesophageal reflux disease (GERD), or allergy-related postnasal drip.18 Pharyngitis secondary to GERD or allergies would likely accompany symptoms of dyspepsia or nasal congestion with postnasal drip, respectively. It is one of the most common reasons for visits to family physicians. It can happen when your pharynx (the back of your throat) becomes inflamed. As discussed above in the pathophysiology section, the most common bacterial cause of pharyngitis is GABHS, occurring in 5 to 30% of cases. Some physicians will begin antibiotic therapy presumptively for patients with severe symptoms who meet three or four of the Centor criteria, and may not send a diagnostic test in addition to testing. The overall incidence would be even less, but patients do not always present for evaluation until complications have begun.4 Signs and symptoms related to abscess formation include a more ill-appearing patient with a hot potato voice, deviation of the uvula or uneven palate, and occasionally a visible fluctuant peritonsillar mass. However, no single element in the history or physical examination is sensitive or specific enough to exclude or diagnose strep throat.1,4 This dilemma has inspired investigators to develop scoring systems to facilitate the diagnostic process.4,18,24, In one study, investigators identified four findings from the history and physical examination that independently predicted a positive throat culture for GABHS in a population of adults and children.26 [Evidence level B, observational study] The findings were tonsillar exudates, anterior cervical lymphadenopathy, absence of cough, and history of fever higher than 38C (100.4F). But when the soreness lingers or comes back frequently, it's called chronic pharyngitis. Vaginal, cervical, penile, and rectal cultures also should be obtained when gonococcal pharyngitis is suspected.27,33. Sexually transmitted diseases treatment guidelines, 2015. Pharyngitis is a leading cause of pediatric ambulatory care visits. A typical viral pharyngitis should resolve within 5 to 10 days, if not sooner. EBV is also associated with posterior cervical lymph adenopathy, splenomegaly, and a classic maculopa-pular rash that develops if patients receive penicillin-derived antibiotics. Summary of common signs and symptoms of viral, bacterial, and fungal pharyngitis: Signs and symptoms of bacterial pharyngitis can overlap with those of streptococcal pharyngitis. These should be immediately treated along with urgent or emergency otolaryngologist consultation. Group C streptococci also may cause pharyngitis, but would ultimately be distinguished by a RAD test or throat culture. Dumkow LE, Axford KL, Suda KJ, Draper HM, Brandt KL. They are characterized by the sudden onset of fever, sore throat, and painful swallowing. A more recent article on streptococcal pharyngitis is available. Hogan CA, Caya C, Papenburg J. Kocoglu E, Karabay O, Yilmaz F, Ekerbicer H. The impact of incubating the throat culture for 72 h on the diagnosis of group A beta-hemolytic streptococci. The entire range of supportive therapies, including analgesic and antipyretic medicines, oral hydration, and rest, should be considered for every patient whose symptoms warrant them. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. One must be suspicious of symptoms that worsen or persist beyond clinical expectations. . Viral pharyngitis, the most common cause of sore throat, has a wide differential. She had similar symptoms a few years ago, which were treated with antibiotics. Dermatologic features of the disease become apparent within three days of the onset of fever14,18 and include cracked red lips, a generalized polymorphous erythematous rash with edema and erythema of the hands and feet, and periungual desquamation followed by peeling of the palms. Mandell, Douglas, and Bennetts principles and practice of infectious disease. Peritonsillar and retropharyngeal abscesses form in > 1% of patients complaining of sore throat who are treated with antibiotics. Rather, they can rule out atypical infections such as non-GAS and fungal pharyngitis that require alternate antimicrobial regimens.22. HHS Vulnerability Disclosure, Help Trauma or throat strain caused by overuse (shouting, for example) should be elicited via the patient's history of symptom onset. Sources of information The approach described is based on the authors' clinical practice and peer-reviewed literature from 1989 to 2018. Many bacterial and viral organisms are capable of inducing pharyngitis, either as a single manifestation or as part of a more generalized. Antistreptolysin O titre tests are used for patients with suspected suppurative complications of GAS. Given Ms Z.s symptoms and probable fever in the absence of cough and rhinorrhea, pharyngitis is suspected. Before Laboratory testing serves as an adjunct to the history and physical examination (Table 1).1,2,4,6,7,11,17,2327, A systematic review of the clinical diagnosis of pharyngitis1 identified large, blinded, prospective studies using throat cultures as a reference standard. Serologic (positive mycoplasma IgM) or, less often, culture methods can be used to identify this infectious agent, which was found in 33% of college . Pharyngitis is an inflammation of the pharynx that can lead to a sore throat. This test misses about one third of cases in the first week of illness but is more than 80 percent sensitive in the second week. Campagna JD, Bond MC, Schabelman E, Hayes BD. For patients with acute pharyngitis, complications can develop when a bacterial source of infection is not managed properly. Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study. GABHS is the most common bacterial cause of pharyngitis.1618. Penicillin-allergic patients should be treated with eryth-romycin or a first-generation cephalosporin. Pharyngitis is defined as an infection or irritation of the pharynx or tonsils (see the image below). Pharyngitis is a common concern seen in primary care, caused by viral, bacterial, and fungal agents. Second-year resident, Department of OtolaryngologyHead and Neck Surgery at the University of Toronto in Ontario. One of the most common chief complaints in a primary care physician's office is sore throat. Throat may be scratchy and swallowing can be. If a patient has GABHS pharyngitis, a full 10-day course of PCN or other appropriate antibiotic must be completed to eradicate the bacteria from the pharynx and prevent rheumatic fever. Pharyngitis can be part of a generalized upper respiratory tract infection or a specific infection localized in the pharynx. Infection with Streptococcus pyogenes (group A beta-hemolytic streptococci) is the most common bacterial cause of acute pharyngitis and is responsible for an estimated 5 to 15% of sore throat cases among adults [ 3] and 20 to 30% of cases among children [ 2, 4 ]. Main message Alternatively, RADT technology is specific but equally should not guide management in isolation, as its sensitivity can be variable and RADT lacks high-quality evidence in the pediatric population.23 Negative RADT results in patients aged 5 to 15 should be verified with a throat culture.34 Moreover, children younger than 3 should not be tested unless there is a high chance of GAS exposure, as incidence within this population is less than 14% and infection rarely causes acute rheumatic fever.35, Approximately 7% of pediatric and 20% of adult patients are asymptomatic and noninfectious carriers of GAS.36 Superfluous antibiotic use can lead to unnecessary side effects and increase health care costs. Ms. Z is asked to take ibuprofen for pain and to maintain adequate hydration. Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study. Bethesda, MD 20894, Web Policies An abscess would likely cause higher fevers, more discomfort, and persistent symptoms despite typical first-line antibiotic treatment. Penicillin V and rifampin for the treatment of group A streptococcal pharyngitis: a randomized trial of 10 days penicillin vs 10 days penicillin with rifampin during the final 4 days of therapy. The use of cephalosporins in penicillin-allergic patients: a literature review. Occasionally, a scarlatiniform rash may be present, often seen in association with a GABHS infection. Impact of a stewardship-focused culture follow-up initiative on the treatment of pharyngitis in the emergency department and urgent care settings. Gonzalez RM, Varnum SM, Zangar RC. If the patient has none or one of these symptoms, suspicion for GABHS is very low and no further testing or treatment is necessary. This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. A cost-effective analysis. Cocci may be detected on cultures (grown on blood agar), latex agglutination tests, or rapid tests using labeled monoclonal antibodies. government site. Pharyngitis. Another class of available tests are the rapid antigen detection (RAD) tests, which use enzyme or acid extraction from throat swabs, followed by latex agglutination, coagglutination, or enzyme-linked immunoabsorbent assay (ELISA) procedures to isolate GABHS antigenantibody complexes.3 Although older models were not as reliable and variation still exists, newer techniques show a sensitivity ranging from 76 to 97% and a specificity > 95%.8,17 Most modern RAD tests produce results within 10 minutes or less. Randel A, Infectious Disease Society of America. Symptoms often manifest after an incubation period ranging from 1 to 5 days, and occur most commonly in the winter or early spring. Hence, negative results cannot rule out non-GAS bacterial pharyngitis. Sore throat and pharyngitis represent more than 2% and 5% of all outpatient primary care visits for adult and pediatric populations, respectively.1 It is characterized by inflammation of the pharynx, nasopharynx, and tonsillar tissues.2 Incidence peaks between late winter and early spring. Arcanobacterium haemolyticum, formerly known as Corynebacterium haemolyticum, is seen more frequently in teenagers and young adults, and may be accompanied by a scarlatiniform rash. The approach described is based on the authors clinical practice and peer-reviewed literature from 1989 to 2018. Other less common causes of pharyngitis include allergies, trauma, cancer, reflux, and certain toxins. Those at risk of complications (elderly, frail, immunocompromised) might benefit from RADT to rule out bacterial causes. In recent years, fear of GABHS infection and its possible complications, and growing expectation of antibiotic prescriptions by patients has resulted in overuse of antibiotics for treatment of acute pharyngitis. The defining characteristic of this bacteria is the development of a firmly adherent, gray, inflammatory pseudomembrane across the oropharynx. Pharyngitis is inflammation of the pharyngeal tissues, and is usually associated with pain. Common causes of lowered immunity include HIV, diabetes, treatment with steroids or chemotherapy drugs, stress, fatigue, and poor diet. 2005 May:33. Reported cases of Corynebacterium diphtheriae are very rare because of childhood vaccinations, but patients with this variety of pharyngitis will frequently complain of hoarseness and stridor caused by circulation of the diphtheria exotoxin, and may also experience cervical adenitis and edema. A patient presenting with primary HIV may complain of sore throat as well as several other flu-like symptoms, but they are likely to have HIV risk factors in their history (e.g., unprotected intercourse, multiple sexual partners, previous blood transfusion, and intravenous drug use). The site is secure. Chlamydia pneumoniae or Mycoplasma pneumoniae can cause lower respiratory symptoms that are more severe, such as bronchitis, pneumonitis, or pneumonia, in addition to pharyngitis. Acute tonsillitis may be defined as inflammation of the tonsils, predominantly due to infection. Offering a RAD test or throat culture to those patients with two, three, or four of these criteria will help delineate which patients may need antibiotic treatment. Sore throat is one of the most common reasons for visits to family physicians. Cet article est disponible en franais. Guidelines for the antibiotic use in adults with acute upper respiratory tract infections. FeverPAIN scoring system: Developed in the United Kingdom for calculating the risk of streptococcal pharyngitis in patients presenting with sore throat. Second, based on the above assessment, the physician must determine which laboratory tests, if any, should be carried out to ensure the proper diagnosis. This article is eligible for Mainpro+ certified Self-Learning credits. Given the above historical and physical findings, a number of clinical tools have been established to help determine whether GABHS is the likely causative pathogen. The most common bacterial cause of pharyngitis, GABHS, is also known as Streptococcus pyogenes and may exist as single, paired, or chained gram-positive cocci. Under ideal circumstances, and often using two samples, the sensitivity and specificity of such cultures reaches 97% and 99%, respectively.17 In most offices, however, those numbers vary widely, with a sensitivity between 30 and 90% and a specificity from 75 to 99%.8 Some false positive results can be expected with culture results because up to 20% of the US population may be chronic, asymptomatic GABHS carriers. When the clinical scenario suggests the presence of infectious mononucleosis, the diagnosis may be obtained by the presence of a positive heterophil antibody test (Monospot test) for Epstein-Barr virus. Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Case fatality rates for noncutaneous diphtheria (5 to 10 percent) have remained constant for the past five decades.23 Diphtheria pharyngitis has recently (March 2001) been reported in Delaware County, Pa.24. Treatment involves GABHS antibiotic coverage for any subsequent pharyngitis attacks and therapy for all clinical manifestations. Rheumatic fever is exceedingly rare in the United States and other developed countries (annual incidence less than one case per 100,000).21 This illness should be suspected in any patient with joint swelling and pain, subcutaneous nodules, erythema marginatum or heart murmur, and a confirmed streptococcal infection during the preceding month. Rapid antigen detection tests should be reserved for concerns about antibiotic initiation. She appears to be distressed and in pain when swallowing but does not appear severely ill. She is febrile and examination reveals an enlarged cervical lymph node on her left side, along with bilateral tonsillar hypertrophy without exudates. It is usually caused by viral and/or bacterial infections, such as the common cold and flu (both viral infections) or by infection with the Streptococcus bacterium (strep throat). Because of recent improvements in rapid streptococcal antigen tests, throat culture can be reserved for patients whose symptoms do not improve over time or who do not respond to antibiotics. sharing sensitive information, make sure youre on a federal Dermatologic manifestations in concert with characteristic signs and symptoms serve as diagnostic criteria.13. Cheung L, Pattni V, Peacock P, Sood S, Gupta D. Throat swabs have no influence on the management of patients with sore throats. The approach described is based on the authors clinical practice along with research and clinical review articles from 1989 to 2018. Additional evaluation is required to investigate for the presence of a foreign body, neoplastic lesions, and other unusual causes of sore throat. Group A strep pharyngitis can occur in people of all ages. Pharyngitis is an inflammation of the pharynx that can lead to a sore throat. Symptoms of pharyngitis can include discomfort, dryness, and difficulty swallowing. Furthermore, different viruses are more prevalent during certain seasons.4 Coryza, conjunctivitis, malaise or fatigue, hoarseness, and low-grade fever suggest the presence of viral pharyngitis.12 Children with viral pharyngitis also can present with atypical symptoms, such as mouth-breathing, vomiting, abdominal pain, and diarrhea.8,12, Infectious mononucleosis is most common in patients 15 to 30 years of age.13 Patients typically present with fever, sore throat, and malaise.
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