PANCE Blueprint EENT (7%)

Acute pharyngitis (ReelDx + Lecture)


Strep Pharyngitis

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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(Bonus ReelDx) – A case of scarlet fever


Strep Pharyngitis

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.

Diseases caused by Group A Strep

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.
Presentation (bacterial) Evaluation Treatment Image
  • High fever
  • A severe sore throat
  • No cough
  • Edematous tonsils with white or yellow exudate
  • Cervical adenopathy
  • Rapid antigen agglutination kit for screening
  • Throat swab culture is the gold standard
  • Penicillin to prevent acute rheumatic fever
  • If allergic, erythromycin or a first-generation cephalosporin

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
Presentation (viral) Evaluation Treatment Image
  • Sore throat
  • Fever
  • Red eye
  • Clinical
  • Supportive

III. Fungal Pharyngitis

  • Common in patients using inhaled steroids – counsel patients to rinse mouth after use of inhaled steroids.
Presentation (fungal) Evaluation Treatment Image
  • Sore throat
  • Dysphagia
  • Cheesy white patches in the oropharynx
  • Seen in AIDS patients and small children
  • Clinical or endoscopy
  • Clotrimazole troches (one 10-mg troche dissolved slowly five times daily)
  • Miconazole mucoadhesive buccal tablets (50 mg once daily applied to the mucosal surface over the canine fossa)
  • Nystatin swish and swallow (400,000 to 600,000 units four times daily)
  • Fluconazole in HIV + patients

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

osmosis Osmosis

_DM_Penicillin_v1.6_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
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Rheumatic fever
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Post streptococcal glomerulonephritis
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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.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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