PANCE Blueprint EENT (7%)

Acute pharyngitis (ReelDx + Lecture)


Strep Pharyngitis

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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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 the gold standard
    • Rheumatic fever and post-strep glomerulonephritis
  • Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis.
Presentation Evaluation Treatment Image
  • High fever
  • A severe sore throat
  • No cough
  • Edematous tonsils with white or yellow exudate
  • Cervical adenopathy
  • Antigen agglutination kit for screening
  • Throat swab culture is 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 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 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 criteria: 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: 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

_DM_Penicillin_v1.6_ Penicillin, derived from the Penicillium fungi, is the first antibiotic that successfully treated previously deemed critical diseases such as syphilis, staphylococcus and streptococcus infections. There are different forms of penicillin such as penicillin G, penicillin V, benzathine penicillin, etc. All penicillins are beta-lactam antibiotics, and they are still widely used today for gram positive organisms and spirochetes.

Penicillin works via a few different mechanisms. First, it binds to the penicillin-binding protein (PBP), which is also known as the enzyme transpeptidase, to disrupt normal bacterial cell wall synthesis. Penicillin blocks transpeptidase (PBP), a critical enzyme involved in the peptidoglycan cross linking in the bacterial cell wall. This causes bacterial death from osmotic pressure induced cytolysis. Penicillin’s small size allows it to penetrate deeply into the cell wall. Another mechanism is that penicillin activates autolytic enzymes in the bacteria to cause cell death. This antibiotic is classified as bactericidal because it actually causes bacterial cell death.

Common adverse reactions from penicillin include hypersensitivity reactions. High doses of penicillin can also induce immune mediated hemolysis due to a hapten mechanism, which is when the antibodies target the combination of penicillin in association with the red blood cells and activate complements to induce hemolysis and removal of red blood cells.

Penicillin Picmonic

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.
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