Case discussion03/08/2013

Dr. Babu Lal MeenaPGIMER, Chandigarh

Aims and objectives

• Approach to a case of pharyngitis

• Relevant work up

• Soft points to differentiate b/w viral and bacterial

pharyngitis

• Appropriate use of antibiotics

M, 6 year, Fch

History

History of present illness

Fever

4 days

Throat pain

4 days

History of present illness

•Fever

•4 days, acute onset

•Up to 102 ⁰F

•No chills/ rigor

•Responding to antipyretics

•Pain in the throat

• 4 days

• Continuous

• No aggravating or relieving factor

•No h/o

• Difficulty in breathing, cough

• Snoring/nasal obstruction

• Redness/watering of eyes

• Hoarseness of voice

• Dysphagia/decreased food intake

• Earache/ear discharge

•Past- no allergy,

recurrent sore throat

•Antenatal and Birth

• Uneventful

•Development -normal

•Immunization

• According to NIS

•Dietary history-normal

History cont. . .

Family:- Non

consanguineous marriage

No history of similar illness

No history of smoking

Low socioeconomic status

Overcrowding

Physical examination

•Vital

•HR-118/min, RR-20/min

•PP/CP ++/++

•BP-100/70

•No-Pallor/edema/

cyanosis

•Throat examination

• B/L Tonsilar

enlargement +

Grade-II, exudates +

No bleeding on

scrapping the exudate

• Congested pharynx

•Cervical lymphnode

• Anterior cervical

• Palpable, 2X2 cm

• Tender, firm

• No discharging sinus

•Nose and ear normal

•Skin-normal

Examination cont. . .

• Respiratory

• NVBS

• No added sounds

• CVS

• S1S2-normal

• No murmur

•Abdomen

• Soft

• No organomegaly

•CNS

• Normal

Database

6 yr, Fch, R/O Chandigarh, Lower socioeconomic family

Overcrowded residence

Immunized for age

Acute febrile illness with throat pain

Tender cervical lymphadenopathy

Tonsilar enlargement with exudates on tonsil and pharynx

Systemic examination-Normal

Possible Etiology

Nelsons 19th edition

Viruses

• Adenoviruses

• Coronaviruses

• Rhinoviruses

• Parainfluenza

• Influenza

• HIV, EBV

• HSV

Bacterial

• GABHS- 13.4%(India)

15-36% (West)

• Group C, G

streptococcus

• Diphtheriae

• Uncommon

• Chlamydia

• Mycoplasma

Other Causes Of Sore Throat

• Peritonsillar, Retropharyngeal and Lateral Pharyngeal abscesses

• Allergies-complicated by post nasal drip

• Irritants—Dust, tobacco smoke (in teenagers) or chemicals

• Muscle strain, psychogenic

• GastroEsophageal Reflux Disease (GERD)

Indian journal of pediatrics: JUNE 2011, Sunit.C.Singhi

Bacterial or Viral ??

BacterialAcute onset

Throat pain

Pharyngeal exudates

Tender anterior lymphadenopathy

Absence of Cough, nasal discharge

Work-Up

Throat culture GABHS

Sensitive MethicillinClindamycinErythromycinAzithromycin

Final diagnosis

Acute Pharyngitis

Tonsillitis

Etiology-Group A Beta Hemolytic Streptococci

Introduction

Indian journal of pediatrics: JUNE 2011, Sunit.C.Singhi

•Pharyngitis

• Inflammation of the pharynx

• Exudates, ulceration, or definite erythema

•Sore throat presenting symptom in 1/3rd of URI

•Etiology is bacterial and viral

•1/4th of patient can have bacterial pharyngitis

Usual Presentation

Viral pharyngitis

•Gradual onset

•Low grade fever

•Running nose, cough

•Conjunctivitis, hoarseness

•Herpangina

•Lymphadenopathy

•Hepatosplenomegaly

Nelsons-19th edition

GABHS

•Peak- early school years

•Winter and spring season

•Respiratory secretions

•Spreads among siblings

and classmates

•Incubation period- 2 to 5

days

GABHS

•Rapid onset

•Prominent sore throat

•Absence of cough, Fever

•Headache and GI symptoms seen

•Pharynx red, Tonsils enlarged

•Exudates

•Tender anterior cervical

lymphadenopathy

Usual Presentation

GABHS v/s Viral Pharyngitis

Indian journal of pediatrics: JUNE 2011, Sunit.C.Singhi

Regoli et al. Italian Journal of Pediatrics 2011, 37:10

Approach

Indian journal of pediatrics: JUNE 2011, Sunit.C.Singhi

Clinical features-Investigations

Main aim is to pick up a case of GABHS and Diptheria

1. Throat swab- Gram stain & culture and Albert stain

2. RADTs for GABHS

3. Other investigations

• Complete blood count

• Peripheral smear for atypical lymphocytes

• EBV serology

4. If abscess suspected

• X-ray soft tissue neck (lateral)

• CT scan involving base of skull

Throat culture Rapid antigen diagnostic test

• Gold standard

• Requires 18-24 hrs incubation @

37 ⁰C

• False positive

• Streptococcal carriers

misidentification as GABHS

• False negative

• Inadequate throat specimen

• Antibiotics use

•Identify GABHS in minutes in a

throat swab

•Specificity is high 98%

•Sensitivity vary – 70%

•Nitrous acid extraction of group

A carbohydrate antigen

diagnosisDiagnosis

Throat swab sampling technique

• Samples should be obtained by vigorous swabbing of both

Tonsillar surfaces or fossa and the posterior pharynx

• Correctly sampled and plated, throat swab culture has 90–95%

sensitivity

Treatment

•Rest during fever

•Increased intake of

• nonacid and nongaseous fluids

• foods with pasty consistency

•Analgesic/antipyretic

•Irrigation of the pharynx with warm isotonic saline solution.

General measures

Antimicrobial treatment

When to give antibiotics???

Treatment

Antibiotic therapy

Regoli et al. Italian Journal of Pediatrics 2011, 37:10

Score Risk of GABHS infection

Action

≤0 or1 1-10% No testing

2 11-17% Testing

3 28-35% Testing

≥4 51-53% TestingEmpirical antibiotics

American academy of pediatrics 2009, 1:79(5) 383-390

•Hasten the clinical recovery

•If initiated early (9 days) prevents acute rheumatic fever

•Prevent suppurative complications

•Reduce communicability

Antibiotic therapy

Regoli et al. Italian Journal of Pediatrics 2011, 37:10

Index case

•Had a centor score- 5

•Hence

• Throat culture sent

• Antibiotics was given

Symptomatic pharyngitis with :-

• Clinical diagnosis of scarlet fever

• A positive rapid streptococcal antigen test

• Household contact with doccumented GABHS pharyngitis

• Past h/o acute rheumatic fever

• A recent h/o acute rheumatic fever in family member

Indication for antibiotic therapy

Clinical pointers to a GABHS infection

Indication for Hospitalization

• Toxic looking child

• Not accepting orally well

• Suspected to having associated complications or diphtheria.

Nelson 19th edition

• Pencillin is the drug of choice (no resistance)

• Oral ampicillin/amoxicillin is equally effective

• Standard duration of therapy is for 10 days

• A single intramuscular dose of benzathine penicillin

(600,000 U for children <27 kg & 12,00,000 U for larger children

and adults)

Drug of choice???

Indian journal of pediatrics: JUNE 2011, Sunit.C.Singhi

Carrier state

The treatment regimen most effective for eradicating streptococcal

carriage is Clindamycin, 20 mg/kg/day divided in 3 doses orally for

10 days.

The overall prevalence of GAS was 37%

Children who were younger than 5 years had a lower prevalence

of GAS 24%

The prevalence of GAS carriage among well children with no signs

or symptoms of pharyngitis was 12%

•Cervical lymphadenitis

•Peritonsillar abscess

•Retropharyngeal abscess

•Otitis media, Mastoiditis

•Sinusitis.

•Acute rheumatic fever (ARF)

•PSGN

•Sydenham chorea

•Reactive arthritis

•PANDAS

SUPPURATIVE COMPLICATIONS NON SUPPURATIVE COMPLICATIONS

Complications

Index Case

General measures advised

Paracetamol given

Amoxicillin given 40mg/kg/day for 10 days

Take Home Message

•Soft points to differentiate between viral and bacterial

infection

•Rationale of using antibiotics in sore throat

•Early diagnosis and treatment of GABHS pharyngitis can

prevent life threatening complications

Thank you