approach to sore throat in children
-
Upload
babu-lal-meena -
Category
Health & Medicine
-
view
366 -
download
1
description
Transcript of approach to sore throat in children
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