Know the difference between Epstein-Barr virus (EBV) and strep pharyngitis
Know the difference between Epstein-Barr virus (EBV) and strep pharyngitis: Excerpt from Avoiding Common Pediatric Errors
Author:
Sarika Joshi, MD
What to Do - Interpret the Data
Sore throat is a common complaint from children and adolescents that often prompts physician visits. Many infectious agents are known to cause
pharyngitis, and most require only supportive care. Two important causes of
pharyngitisthatshouldberecognizedbycliniciansaregroupAstreptococcus
(GAS, Streptococcus pyogenes) and EBV.
GAS pharyngitis occurs most commonly in school-aged children and
accounts for 15% to 30% of all cases in children ages 5 to 15 years. The peak
seasons forGASpharyngitisarelatefall,winter,andearly spring.Classically,
GAS pharyngitis has an abrupt onset and is associated with fever, headache,
and abdominal pain. The common symptoms of viral upper respiratory
infections, such as cough, rhinorrhea, and nasal congestion, are typically
absent. Only 15% of patients will present with the classical constellation of
signs and symptoms of acute pharyngitis with edema, erythema or exudates,
and sometimes palatal petechiae and anterior cervical lymphadenopathy.
Spontaneous resolution usually occurs in 3 to 5 days.
A throat culture is the gold standard method for the diagnosis of GAS
pharyngitis. The throat culture, performed by sampling both tonsillarpillars
and the posterior pharynx without touching the buccal mucosa or tongue, is
incubated for at least 18 to 24 hours. Because of this delay, most physicians
perform both a rapid antigen detection test and a throat culture. The specificity of the rapid test is very high, meaning that there are few false positives,
but the sensitivity can be as low as 65%, which is why it is also imperative to
send the throat culture to the laboratory. It is important to note that neither
of these tests can distinguish between acute infection versus chronic carriage
of GAS.
Appropriate antibiotic treatment of GAS pharyngitis helps to prevent the local suppurative complications, as well as the nonsuppurative
complication of acute rheumatic fever (ARF). Local suppurative complications include otitis media, sinusitis, lymphadenitis, and retropharyngeal and
peritonsillar abscesses. Antibiotic treatment has not been shown to prevent
glomerulonephritis, another known nonsuppurative complication of GAS
infection. Treatment with oral penicillin is the current first-line recommendation for GAS infections. Recommended treatment for penicillin-allergic
patients is with erythromycin.
EBV isthe usual etiologic agent for infectiousmononucleosis,which occurs most commonly in adolescents.Despite high rates of exposure, children
develop clinical infection <10% of the time, whereas adolescents develop
symptoms >50% of the time. Classically, infectious mononucleosis presents
with fever, pharyngitis, and posterior cervical lymphadenopathy, although
lymph node involvement may be more generalized. Unlike GAS pharyngitis, the onset of infectious mononucleosis is often insidious with a prodrome
of malaise and headache. The patient's exam reveals acute pharyngitis with
edema, erythema or exudates, and sometimes palatal petechiae, similar to
GAS pharyngitis; however, the edemawith infectiousmononucleosis maybe
so severe as to cause airway impingement. Other associated findings with infectious mononucleosis include splenomegaly and severe fatigue. The acute
symptoms generally resolve in 1 to 2 weeks, but the fatigue may persist for
months.
The diagnostic workup for infectious mononucleosis starts with blood
work—a white blood cell count with differential and a heterophile antibodies test. Characteristically, there are 60% to 70% lymphocytes with >10%
atypicallymphocytes, althoughtheseare notspecific forEBVinfection.Heterophile antibodies are the test of choice, since they are both sensitive and
specific, about 85% and 100%, respectively. If heterophile antibodies are
negative and the clinical suspicion for infectious mononucleosis is strong,
EBV-specific antibodies may be drawn.
The mainstay for treatment of infectious mononucleosis is supportive
care. If a patient is misdiagnosed (i.e., with GAS pharyngitis) and treated
withamoxicillinorotherantibiotics,anonspecificrashmaydevelop.Corticosteroidsmaybewarrantedinseverecaseswithimpendingairwayobstruction.
ArarebutimportantcomplicationofEBVinfectionissplenicrupture,which
is spontaneous more than 50% of the time and usually occurs in the first 3
weeks of symptomatic illness. Due to this potential risk of splenic rupture,
return to sports is a common clinical question. In general, noncontact sports
can be resumed 3 weeks after symptom onset, whereas contact sports require
a minimum of 4 weeks, if the patient does not have splenomegaly.
GAS and EBV are important pathogens of pharyngitis in children and
adolescents. Diagnosis and appropriate antibiotic treatment for GAS helps
to prevent the complication of ARF. Diagnosis of EBV infection alerts the
physician to watch for the potentially life-threatening complications of airway obstruction and splenic rupture.
Suggested Readings
Bisno AL. Acute pharyngitis: etiology and diagnosis. Pediatrics. 1996;97(6 Pt 2):949–954.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev.
2000;(4):CD000023.
Rea TD, Russo JE, Katon W, et al. Prospective study of the natural history of infectious
mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract. 2001;14:234–242.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Epstein-Barr virus
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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