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Epidemiology

Adenovirus

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

• Bacterial
  

  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 > 100.4^oF (38^oC)
• 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

• 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

• 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

• 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 ≥ 38^oC (+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
    

    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

• • 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
    • Deviated uvula, “hot potato voice”, adolescents, soft palate swelling
• Diptheria
  • Unimmunized, recent travels to endemic country, gray-pseudomembrane
• Lemierre Syndrome
  • Fusobacterium sp. or mixed anaerobes, toxic appearance, recent jugular line placement

Treatment

Cottage Physician Reference

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.