Pharyngitis

Pharyngitis: Excerpt from The 5-Minute Pediatric Consult

Mark L. Bagarazzi, MD

Pharyngitis - BASICS

Pharyngitis - description

Pharyngitis (i.e., sore throat) is an inflammation of the mucous membranes and underlying structures of the pharynx and tonsils, usually secondary to viral or bacterial infection.

Pharyngitis - general prevention

Control measures:

• Children with group A streptococcal (GAS) pharyngitis can return to school or day care 24 hours after starting antimicrobial therapy.
• Cultures of asymptomatic contacts of patients with streptococcal pharyngitis are not indicated except in outbreak situations in school or day care (where treatment of patients with positive rapid streptococcal antigen detection test [RADT] or culture is indicated) or in contacts with a history of nonsuppurative complications.

Pharyngitis - etiology

• Viral:
  • Adenovirus types 1–7, 7a, 9, 14, 15, and 16
  • Epstein–Barr virus (EBV)
  • Influenza A, B: Usually associated with more severe systemic complaints
  • Parainfluenza 1, 2, and 3
  • Enteroviruses: Coxsackie A and B and echoviruses
  • Measles, rubella, coronavirus, and cytomegalovirus
  • Herpes simplex virus (HSV)
  • Rhinovirus and respiratory syncytial virus (RSV): Not usually associated with pharyngeal inflammation
  • HIV
• Bacterial:
  • Streptococcus pyogenes (group A β-hemolytic streptococcus)
  • Group C or G streptococci
  • Corynebacterium diphtheriae (diphtheria)
  • Corynebacterium hemolyticum
  • Neisseria gonorrhoeae and Neisseria meningitidis
  • Mycoplasma pneumoniae and Mycoplasma hominis
  • Chlamydia pneumoniae, Chlamydia psittaci
  • Yersinia enterocolitica
  • Treponema pallidum (syphilis)
  • Oral anaerobes (Vincent angina)
• Fungi: Candida species (oral thrush)

Pharyngitis - DIAGNOSIS

Caution: Diagnostic pitfalls:

• Swabbing the throat from anywhere other than the tonsils and posterior pharyngeal wall
• Even experienced clinicians may overestimate the diagnosis of GAS pharyngitis by up to 80%, using clinical grounds alone.
• GAS pharyngitis may go unrecognized in ~20% of children who have mild symptoms if cultures are not performed.
• Failure to use throat culture to rule out streptococcal pharyngitis when rapid test is negative
• Failure to request identification of other organisms in the appropriate clinical setting (e.g., N. gonorrhoeae or A. hemolyticum)
• Reliance on Monospot test in young children (<5 years of age) because of a high incidence of false negatives (consider EBV serology instead)
• Positive throat culture or RADT in patients with viral pharyngitis may represent streptococcal carrier state. Diagnostic tests for GAS should be used in patients suspected of having streptococcal disease on clinical and epidemiologic grounds, not on all patients who complain of a sore throat.

Pharyngitis - signs & symptoms

• Sore throat
• Fever
• Headache
• Nausea, vomiting
• Rhinorrhea
• Cough, hoarseness
• Conjunctivitis
• Ulcerative pharyngeal lesions

Pharyngitis - history

• Sudden onset of fever with headache, nausea, and vomiting: Frequent in streptococcal pharyngitis, which is usually exudative but with cough or rhinorrhea in only ~10% of cases
• Pharyngitis associated with rhinorrhea, cough, hoarseness, conjunctivitis, and ulcerative pharyngeal lesions: More likely to have a viral cause but GAS pharyngitis cannot be ruled out on this basis
• Significant systemic complaints such as fever and malaise: Characteristic of EBV or HIV (acute retroviral syndrome)
• Swimming in an inadequately chlorinated pool: Consider adenoviral pharyngoconjunctival fever.
• Appearance of papular eruption after administration of ampicillin or amoxicillin: Consider EBV.
• Ingestion of undercooked meat or handling of rabbits: Consider tularemia.

Pharyngitis - physical exam

• Tonsillar enlargement and moderate to severe pharyngeal erythema, which may be associated with petechiae, exudate, or ulceration
• Follicular, exudative pharyngotonsillitis that may occur in association with conjunctivitis: Common with adenovirus infections (e.g., pharyngoconjunctival fever)
• Ulcerative lesions or characteristic enanthem consisting of 2–14 ulcers and vesicles (1–2 mm) in the posterior pharynx: Common with enteroviral infections (e.g., Coxsackie A, B, echovirus)
• Ulcerative lesions on anterior oropharynx (gingivostomatitis): Characteristic of HSV infection, which can also cause an exudative pharyngitis in adolescents that may be difficult to differentiate from streptococcal or EBV pharyngitis
• Varying degrees of cervical adenopathy: Tender anterior lymphadenopathy more likely associated with streptococcal disease
• Presence of an adherent membrane that may extend from the tonsils, uvula, and pharyngeal walls to the larynx and trachea with foul or sweet odor to breath and/or severe lymphadenitis creating “bull neck” appearance: Suggests diphtheria
• Splenomegaly and/or generalized adenopathy: Suggests EBV

Pharyngitis - tests

Pharyngitis - lab

• RADT:
  • As effective as initial tests with >95% specificity and 50–80% sensitivity
  • Cultures should be performed when rapid test is negative.
  • Hint: Culture throat using 2 swabs initially, keeping 1 for culture if the rapid test is negative.
  • Positive rapid tests do not require culture confirmation.
  • The best technique is to swab both tonsillar pillars and the retropharynx.
• Throat culture: Gold standard with best sensitivity (>90%) for group A β-hemolytic streptococci
• Monospot (heterophil antibody) test or EBV serology:
  • For infectious mononucleosis: Rate of heterophil antibody response appears to increase from infancy up to 4 years, after which the rate of response approaches values similar to those reported in young adult patients.

Pharyngitis - differencial diagnosis

• Infectious:
  • Herpangina (enterovirus)
  • Hand, foot, and mouth disease (enterovirus)
  • Peritonsillar abscess or cellulitis
  • Retropharyngeal abscess or cellulitis
  • Laryngitis
  • Epiglottitis
  • Kawasaki disease
  • Tularemia
• Ingestions:
  • Caustic or irritant ingestions
  • Inhaled irritant
• Tumors:
  • Leukemia
  • Lymphoma
  • Rhabdomyosarcoma
• Trauma: Vocal abuse from shouting
• Inflammatory: Allergy
• Miscellaneous:
  • PFAPA syndrome (periodic fever, aphthous ulcers, pharyngitis, and cervical adenitis)
  • Psychogenic pain (globus hystericus)
  • Vitamin deficiency (A, B complex, C)
  • Dehydration

Pharyngitis - TREATMENT

Pharyngitis - general measures

• Usually no therapy indicated, except for streptococcal pharyngitis (and other rare cases of bacterial or fungal pharyngitis)
• May withhold treatment for GAS pharyngitis until throat culture result is available
• Steroids have not been found to significantly alter the course or symptoms of acute pharyngitis and are not recommended.

Pharyngitis - medication

Pharyngitis - first line

• Oral penicillin V is the drug of choice for GAS pharyngitis except in penicillin-allergic individuals. Resistant strains have not been documented in vitro.
  • Children: 400,000 U (250 mg) b.i.d. or t.i.d. for 10 days
  • Adolescents/Adults: 800,000 U (500 mg) b.i.d. for 10 days or 400,000 U (250 mg) t.i.d. or q.i.d. for 10 days
• IM benzathine penicillin G: Ensures compliance, useful in outbreaks:
  • Children (<60 lb [27.2 kg]): 600,000 U IM (1 dose)
  • Children (>60 lb [27.2 kg]) and adults: 1,200,000 U IM (1 dose)
  • Procaine penicillin combinations are less painful.
  • Treatment failures with penicillin have risen steadily leading some experts to recommend other agents as first-line (e.g., cephalosporins). Failures occur even with benzathine penicillin (up to 37%); therefore, compliance is not the cause. Potential causes include presence of β-lactamase–producing normal oropharyngeal flora that may be protecting GAS by inactivating penicillin.

Pharyngitis - second line

• Amoxicillin, clindamycin, and 1st-generation oral cephalosporins (≤15% of penicillin-allergic persons are also allergic to cephalosporins) are reasonable alternatives to penicillin in GAS pharyngitis:
  • Amoxicillin suspension is reported to be more palatable than penicillin VK in young children for whom palatability may affect compliance.
• Clarithromycin and azithromycin have also been shown to eradicate streptococci; however, because of the broad spectra of these antibiotics and the increasing incidence of antibiotic-resistant bacteria, penicillin is still recommended by most experts except in cases of penicillin hypersensitivity, when patient nonadherence to a 10-day penicillin regimen is suspected, or for patients who fail therapy with a β-lactam:
  • Tetracyclines and sulfonamides should not be used owing to resistance of GAS.

Pharyngitis - surgery

Tonsillectomy for recurrent pharyngitis is still controversial with only modest reductions in the number of subsequent episodes weighed against the morbidity of the procedure.

Pharyngitis - FOLLOW UP

• Duration of therapy: Recent trials comparing 10-day courses of penicillin with newer oral cephalosporins or macrolides used for 3–5 days have shown similar bacteriologic and clinical cure rates; however, efficacy in prevention of nonsuppurative sequelae (e.g., acute rheumatic fever [ARF]) is unknown, and these agents have broad spectra and greater expense.
• Patients with streptococcal pharyngitis: Clinical improvement is usually rapid.

Pharyngitis - prognosis

• Streptococcal pharyngitis:
  • Rare co-infection with pathogens that elaborate β-lactamase (consider therapy with clindamycin) or in cases of a new infection acquired from family or classroom contact (also rare)
  • Morbidity associated with ARF and acute poststreptococcal glomerulonephritis (APGN).
• Viral pharyngitis is usually self-limited.

Pharyngitis - complications

• Streptococcal pharyngitis:
  • Suppurative complications include peritonsillar abscess, cervical lymphadenitis, and mastoiditis.
  • Most significant nonsuppurative complication is ARF.
  • Poststreptococcal glomerulonephritis
• Lemierre syndrome: Postanginal sepsis or necrobacillosis originates as pharyngitis or tonsillitis, then progresses to sepsis and suppurative thrombophlebitis of the internal jugular vein. Septic thromboemboli seed various organs, especially the liver, lungs, and joints.
• Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS) is a recently recognized nonsuppurative complication that now appears to be more common than rheumatic fever or glomerulonephritis.
  • National Institute of Mental Health (NIMH) diagnostic criteria for PANDAS:
    • Presence of obsessive compulsive disorder (OCD) and/or tic disorder
    • Pediatric onset, usually between 3 and 12 years
    • Abrupt symptom onset and/or episodic course of symptom severity
    • Temporal association between symptom exacerbation and group A β-hemolytic streptococcus (GABHS) infection
    • Presence of neurologic abnormalities during periods of symptom exacerbation
  • Some experts remain skeptical that PANDAS is a legitimate diagnosis.
  • Treatment within 9 days of symptom onset appears to be necessary to halt progression of autoimmune antibody response.

Pharyngitis - bibliography

American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, ed. Red Book 2006: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:610–620.
1. Bisno AL, Gerber MA, Gwaltney JM, et al. Diagnosis and management of group A streptococcal pharyngitis: A practice guideline. Clin Infect Dis. 1998;26:1020–1021.
2. Casey JR, Pichichero M. Meta-analysis of cephalosporin vs penicillin treatment of group A streptococcal tonsillopharyngitis in children. Pediatrics. 2004;q113:866–882.
3. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: Clinical description of the first 50 cases. Am J Psychiatry. 1998;155:264–271.

Pharyngitis - CODES

Pharyngitis - icd9

• 034.0 Pharyngitis (streptococcal)
• 462.0 Pharyngitis (acute, viral, infective)
• 487.1 Pharyngitis (influenza)
• 074.0 Pharyngitis (coxsackie)

Pharyngitis - FAQ

• Q: Are RADTs alone adequate for the diagnosis of GAS pharyngitis?
• A: No, only if they are positive. A negative RADT result should be confirmed by the more sensitive culture.
• Q: How many days after onset of GAS pharyngitis will therapy be effective in preventing ARF?
• A: Therapy started as late as 9 days after illness onset has been shown to be effective in preventing ARF.
• Q: Is there any benefit to starting therapy while waiting for culture results?
• A: Immediate therapy probably shortens the symptomatic period, but waiting for a positive test result avoids overuse of antibiotics.
• Q: Does an asymptomatic patient with a positive test for GAS from the pharynx (e.g., a chronic carrier) require therapy?
• A: Usually not. Between 8% and 20% of children in school or day care will have asymptomatic carriage of GAS and generally do not require therapy. Exceptions are those with a history of ARF, outbreak situations, or to achieve eradication in families with recurrent episodes of GAS pharyngitis.
• Q: Is there any evidence of GAS resistance to penicillin and other β-lactam antibiotics?
• A: No, GAS has never been found to be resistant to penicillin, but some studies suggest tolerance to penicillin where penicillin is bacteriostatic rather than bactericidal. However, 2–8% of GAS strains will be resistant to macrolides.
• Q: Is tonsillectomy indicated for recurrent GAS pharyngitis?
• A: Rare patients in whom multiple symptomatic episodes of laboratory-confirmed GAS pharyngitis occur despite appropriate therapy may be considered for tonsillectomy.
• Q: Is continuous antimicrobial prophylaxis for recurrent GAS pharyngitis recommended?
• A: No, there is insufficient evidence to show that it is effective, except for preventing recurrences of ARF.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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