#12 – Approach to Sore Throat in Children



Epidemiology

Adenojpg

Adenovirus

  • Viral (most common)
    • Adenovirus (most common)
    • Influenza
    • Enterovirus
    • Ebstein-Barr (EBV)
    • Cytomegalovirus (CMV)

 

  • Bacterial
    Streptococcus_pyogenes

    Streptococcus pyogenes

    • Group A streptococcus (GAS) (most common)
      • Streptococcus pyogenes
    • Mycoplasma pneumoniae
    • Neisseria gonorrhoeae
    • Corynebacteriium diptheriae
    • Fusobacterium necrophorum (Lemierre Syndrome)

 

History

  • Several important historical factors that help differentiate viral from bacterial causes
  • Immunization status
  • Timing
    • Viral – slower onset
    • Bacterial – abrupt onset
  • Fever
    • Viral – afebrile to high-normal temperature
    • Bacterial – tend to be > 100.4oF (38oC)
  • Respiratory Complaints
    • Viral – cough is common
    • Bacterial – cough is often absent
    • Dyspnea – suggests serious causes (see below)
  • Fatigue
    • Can occur in both viral and bacterial, but if prolonged may suggests EBV
  • HEENT
    • Viral – Coryza, ear pain, eye redness and watery drainage
    • Bacterial – no associated complaints
    • Hoarseness
      • Viral – common
      • Bacterial – worry about serious causes (see below)
    • Drooling suggests impending airway collapse and is an emergency
  • Rash
    • Viral – macular with no texture
    • Bacterial – scarlatiniform with “sand-paper”texture
Scarlatiniform Rash

Scarlatiniform Rash

  • Neck pain or swelling
    • Viral – generally negative, but EBV can cause tender lymphadenopathy
    • Bacterial – lymphadenopathy common, investigate serious causes

 

Physical Exam

  • Oropharynx
    • Exudates
      • Viral – Generally negative, but EBV can have
      • Bacterial – hallmark of diagnosis
        • Thick, pseudomembrane suggest diphtheria

Screen Shot 2016-04-22 at 4.22.12 PM

  • Palate
    • Both viral and bacterial can causes
    • Classically associated with EBV and GAS
  • Uvula
    • Viral – may be edematous, but midline
    • Bacterial – generally doesn’t affect it
    • Deviation suggests peritonsillar abscess

tonsils_-_peritonsillar_abscess1337554476726

  • Neck
    • Viral – generally no lymphadenopathy, except with EBV
    • Bacterial – lymphadenopathy common

 

Pretest Considerations

  • Centor Criteria
    • Developed in 1981 to help in the clinical decision making of adults with strep throat in the emergency department
      • 4 Variables
        • Tonsillar exudates
        • Swollen, tender anterior cervical lymphadenopathy
        • Absence of cough
        • History of fever
      • Predicted the probability of being culture positive
        • 0 – 2.5%
        • 1 – 6.5%
        • 2 – 15%
        • 3 – 32%
        • 4 – 56%
  • McIsaac Score
    • Developed in 1998 and further stratified patients based on age
      • 3-14 years (highest risk)
      • 15-44 years
      • > 45 years (negative risk)
  • Modified Centor Criteria (Centor + McIsaac) (MD Calc)
    • Variables
      • Age Range
        • 3-14 years (+1)
        • 15-44 years (0)
        • ≥ 45 years (-1)
      • Exudate or swelling of tonsils (+1)
      • Tender, swollen anterior cervical lymphadenopathy (+1)
      • Temperature ≥ 38oC (+1)
      • Absence of cough (+1)
    • Probability of strep infection
      • 1 point – 5-10%
      • 2 points – 11-17%
      • 3 points – 28-35%
      • 4 or 5 points – 51-53%
    • Testing recommendations
      • No testing if 0 or 1 point
      • Optional testing if 2 points
      • Recommend testing if ≥ 3 points
      • NO RECOMMENDATIONS FOR EMPIRIC TREATMENT

 

Testing Options

  • CAN NOT DIFFERENTIATE ACUTE INFECTION VS CHRONIC CARRIER
    • Up to 21% of children 3-15yo are carriers

      group a streptococci

      Beta-hemolysis

  • Throat culture (gold standard)
    • Sensitivity – 90-95%
    • Testing for hemolysis on sheep blood agar
    • May use RADT if results can’t be obtained in 48hr
  • Rapid Antigen Detection Test (RADT)
    • Sensitivity – 70-90%, but specificity – >95%
    • Tests only for group A strep (S.pyogenes)
  • Decision Pathway for Testing
    • Modified Centor Criteria ≥ 4
      • RADT due to high likelihood of positive culture
      • If RADT negative, perform culture and wait 24hr results for treatment
    • Modified Centor Criteria 2-3
      • Perform throat culture and wait 24hr results for treatment
    • Modified Centor Criteria ≤ 1
      • No testing required

 

Special Testing Considerations

  • Suspect infectious mononucleosis:
    • Often have similar findings to bacterial infections with posterior lymphadenopathy and negative RADT and negative culture
    • Morbilliform rash after starting amoxicillin or ampicillin

Amoxicillin-Rash-Pictures

    • CBC may show lymphocytic predominance
    • Rapid heterophile antibody test (Monospot)
      • Only positive after 2 weeks of illness
    • EBV serology (IgM and IgG)

 

Serious Causes of Sore Throat

  • Epiglottis
    • High fever, toxic appearance, respiratory distress, tripod positioning, drooling
  • Abscess
    • Retropharyngeal
      • Fever, neck pain, trismus, < 4yr
    • Peritonsillar
  • Diptheria
    • Unimmunized, recent travels to endemic country, gray-pseudomembrane
  • Lemierre Syndrome
    • Fusobacterium sp. or mixed anaerobes, toxic appearance, recent jugular line placement

 

Treatment

Screen Shot 2016-04-21 at 1.01.41 PM

Cottage Physician Reference

g

The Cottage Physician. 1893.

References

  1. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. 2005;52(3):729-47, vi.
  2. Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344(3):205-11.
  3. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86-102.
  4. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-46.
  5. Mcisaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83.
  6. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-52.
  7. Gerber MA. Comparison of throat cultures and rapid strep tests for diagnosis of streptococcal pharyngitis. Pediatr Infect Dis J. 1989;8(11):820-4.
  8. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics. 2010;126(3):e557-64.
  9. Rafei K, Lichenstein R. Airway infectious disease emergencies. Pediatr Clin North Am. 2006;53(2):215-42.
  10. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008;138(3):300-6.
  11. Goldenberg NA, Knapp-clevenger R, Hays T, Manco-johnson MJ. Lemierre’s and Lemierre’s-like syndromes in children: survival and thromboembolic outcomes. Pediatrics. 2005;116(4):e543-8.
  12. American Academy of Pediatrics. Group A Streptococcal Infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.732.

 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s