PANCE Blueprint EENT (9%)

Acute pharyngitis (ReelDx)


Strep Pharyngitis

Patient will present with → triad of headache, sore throat and fever suggests strep throat

I. Bacterial pharyngitis:

  • Group A Streptococcal pharyngitis: 5-15% of pharyngitis cases, S. pyogenes. Centor Criteria: GABHS-suggestive manifestations include fever (> 38°C or 100.4°F), tender anterior cervical adenopathy, lack of cough, and pharyngotonsillar exudate.
    • Rapid streptococci screening for GABHS has 90% to 99% sensitivity. If negative and group A streptococci is still suspected, throat culture is gold standard
    • Rheumatic fever and post-strep glomerulonephritis.
  • Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis.

II. Viral Pharyngitis

  • Less likely exudative: CMV, EBV (mononucleosis), adenovirus (most common), influenza, herpes simplex
  • Infectious mononucleosis: Epstein Barr virus - caused by EBV, characterized by malaise, fever, severe sore throat, splenomegaly
    • Rash with penicillins
    • Diagnosed by atypical lymphocytes, heterophile agglutination test (monospot)
    • Splenic rupture possible with trauma/contact sports

III. Fungal Pharyngitis

  • Common in patients using inhaled steroids – counsel patients to rinse mouth after use of inhaled steroids.

Throat culture is the gold standard for diagnosis

Group A Streptococcal pharyngitis: Intramuscular (IM) penicillin can be used if patient compliance is in doubt. Otherwise, an oral penicillin or cefuroxime can be used. Erythromycin or another macrolide can be substituted in cases of penicillin allergy.

  • Inadequate treatment can lead to complications such as scarlet fever, glomerulonephritis, and abscess formation.

Infectious mononucleosis (Epstein Barr virus): Symptomatic and avoid contact sports (splenic rupture), steroids if respiratory distress. Ampicillin and amoxicillin cause rash.

Gonorrhea pharyngitis: Treatment of pharyngeal infection follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections, with a preferred regimen of intramuscular ceftriaxone (250 mg) and azithromycin as a second agent.

No media at this time

Question 1
A 19 year-old college student complains of a sore throat for over a week, with fever and general malaise. On exam T-38°C P-70/minute R-20/minute BP-110/76 mmHg. The patient is alert and oriented x 3. The skin is warm, dry, and without rash. The TMs have a normal light reflex and the canals are clear. The oropharynx is inflamed, with bilaterally enlarged tonsils, and a small amount of exudate. The neck is supple, with anterior cervical adenopathy. The lungs are clear. The heart has a regular rhythm without murmurs. The abdomen is soft, nontender and a spleen tip is palpable. The labs reveal a negative rapid strep screen and positive Monospot. The WBC count is 9,000/microliter with a differential of 40% atypical lymphocytes, 35% lymphocytes, 5% monocytes, 10% eosinophils, and 10% neutrophils. Which of the following is the most appropriate treatment?
Antibiotics are not indicated in the treatment infectious mononucleosis, or Epstein-Barr virus infections.
See A for explanation.
Acyclovir is not approved for use in treatment of EBV, although it is active against the EBV in vitro and in vivo. It may be used in certain patients with AIDS, but has not been shown to affect the outcome of EBV in these patients.
Question 1 Explanation: 
Aspirin or acetaminophen may be used to treat fever and pain associated with infectious mononucleosis, or EBV infection.
Question 2
Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism?
Epstein-Barr virus
Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.
Group C Streptococcus
Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates
Neisseria gonorrhea of the pharynx may be asymptomatic
Question 2 Explanation: 
Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx.
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