8 y/o with sore throat, fever, and loss of appetite
Patient will present as → a 7-year-old boy is brought to his pediatrician for evaluation of a sore throat. The sore throat began 4 days ago and has progressively worsened. Associated symptoms include subjective fever, pain with swallowing, and fatigue. The patient denies cough or rhinorrhea. Vital signs are as follows: T 101.4 F, HR 88, BP 115/67, RR 14, and SpO2 99%. Physical examination is significant for purulent tonsillar exudate; no cervical lymphadenopathy is noted.
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24 y/o with acute onset rash, myalgia, and sore throat
Scarlet fever is a bacterial illness that develops in some people who have strep throat. Also known as scarlatina, scarlet fever features a bright red rash that covers most of the body. Scarlet fever almost always includes a sore throat and a high fever. It most commonly affects children between five and 15 years of age.
Rheumatic fever (acute rheumatic fever) is a condition that can affect the heart, joints, brain, and skin. Rheumatic fever can develop if strep throat, scarlet fever, and strep skin infections are not treated properly.
Poststreptococcal glomerulonephritis (PSGN) results from a bacterial infection that causes rapid deterioration of the kidney function due to an inflammatory response following streptococcal infection. PSGN most commonly presents in children 1 to 2 weeks after a streptococcal throat infection or within 6 weeks following a streptococcal skin infection.
I. Bacterial pharyngitis:
- Group A Streptococcal pharyngitis: 5-15% of pharyngitis cases, S. pyogenes.
- Centor Criteria (MDCalc): Estimates probability that pharyngitis is streptococcal, and suggests management course
- 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, a throat culture is the 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: Caused by Epstein Barr virus, 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.
Centor Score for Strep Pharyngitis (MDCalc): 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy
- Not suggestive of strep - coryza, hoarseness, and cough
- If 3 out of 4 Centor criteria are met, get a rapid streptococcal test (sensitivity > 90%)
- If negative → throat culture is the gold standard
Group A Streptococcal pharyngitis: Intramuscular (IM) penicillin can be used if patient compliance is in doubt. Otherwise, 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
- For athletes planning to resume non-contact sports, training can be gradually restarted starting three weeks from symptom onset
- For strenuous contact sports (including football, gymnastics, rugby, hockey, lacrosse, wrestling, diving, and basketball) or activities associated with increased intraabdominal pressure (such as weightlifting) ⇒ four weeks after illness onset
Fungal: clotrimazole, miconazole, or nystatin
Gonorrhea pharyngitis: follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections
- Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
- For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered
Streptococcus pyogenes is a gram-positive cocci that causes group A streptococcal infections. Strep pyogenes typically produces large zones of beta hemolysis and can be distinguished from other Streptococcal organisms because it is catalase-negative and bacitracin-sensitive. Diseases caused by Streptococcus pyogenes include skin infections like impetigo, cellulitis, pharyngitis, scarlet fever, and toxic shock-like syndrome. Streptococcus pyogenes infections can also precipitate episodes of rheumatic fever and acute glomerulonephritis.
|Streptococcus pyogenes disease||Play Video + Quiz|
|Penicillin||Play Video + Quiz|
|Rheumatic fever||Play Video + Quiz|
|Post streptococcal glomerulonephritis||Play Video + Quiz|
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.
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
References: Merck Manual · UpToDate