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Diseases » Strep throat » Diagnosis
 

Diagnosis of Strep throat

Diagnostic Test list for Strep throat:

The list of medical tests mentioned in various sources as used in the diagnosis of Strep throat includes:

  • Throat swab
  • Rapid strep test (10-20 minutes)
  • Throat swab culture

Strep throat Diagnosis: Book Excerpts

Tests and diagnosis discussion for Strep throat:

Throat is swabbed for culture or for a rapid strep test (10-20 minutes) which can be done in the doctor's office. If the rapid test is negative, a follow-up culture (which takes 24-48 hrs.) may be performed. A negative culture suggests a viral infection, in which case antibiotic treatment should be withheld or discontinued. (Source: excerpt from Group A Streptococcal Infections, NIAID Fact Sheet: NIAID)

Diagnostic Tests for Strep throat: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Strep throat.


SORE THROAT: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there exudates? This is a key question when evaluating a sore throat. Most cases of sore throat with exudates will be found to have streptococcal pharyngitis. Without exudates, one could still have a streptococcal sore throat, but it is less likely.
  2. Is there a temperature elevation? A significant elevation of the temperature, with or without exudates, is also characteristic of streptococcal pharyngitis.
  3. Are there enlarged lymph nodes? If the lymph nodes are enlarged in the peritonsillar area, this is often a sign of streptococcal sore throat, but it certainly is not diagnostic. Interestingly enough, 90% of patients with infectious mononucleosis have posterior cervical adenopathy.
  4. Are there systemic symptoms and signs? Patients who present with exudative tonsillitis and splenomegaly certainly should be considered to have infectious mononucleosis until proven otherwise. Also, an exudative tonsillitis along with a fever and heart murmur should make one consider rheumatic fever. Systemic symptoms such as dry cough, runny nose, and generalized malaise or fatigue should make one think of a viral URI.

DIAGNOSTIC WORKUP

In a sore throat with typical exudates very suggestive of streptococcal pharyngitis, a throat culture may be all one needs before starting definitive antibiotic therapy. In the more difficult cases, screening for streptococcal antigens (streptozyme test and ASO titer) might be indicated. An ASO titer is particularly important when one suspects rheumatic fever. If the patient's streptococcal sore throat persists, a Monospot test and a culture for gonorrhea should be done. Although there are hardly any false-negative Monospot tests, there are 10% false positives, and that should be kept in mind. A blood smear for atypical lymphocytes may be helpful, as well as a heterophile antibody titer in those cases.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Sore Throat: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Viral pharyngitis/laryngitis
    –Most common cause of sore throat
    –Associated with cough, low-grade fever, nasal congestion, and sneezing
    –Influenza occasionally causes sore throat with high fever, cough, severe myalgias
    –Rhino-, adeno-, coxsackie-, and herpesvirus
    –Acute HIV infection
  • Mononucleosis
    –Associated with fever, headache, and excessive fatigue
    –Most common in teen and college ages
    –May have associated lymphadenopathy, splenomegaly, hepatitis, or encephalitis
  • Streptococcal pharyngitis
    –May be associated with scarlatiniform rash, fever >101°F (>38.3°C), exudative pharyngitis, tender cervical lymphadenopathy, and absence of cough
    –More common in winter months, ages 5–10, and with history of group A Streptococcus exposure
  • Allergic pharyngitis
  • Gonococcal pharyngitis
  • Fungal pharyngitis (e.g., Candida)
    • Foreign body in throat
      –Most often occurs in smaller children
      –Associated with sudden onset of audible wheezing, stridor, drooling
    • GERD
    • Sore throat secondary to postnasal drip
    • Irritation secondary to inhalants (e.g., cigarette smoke), chemicals (e.g., alcohol), hot foods
    • Voice abuse (e.g., excessive screaming)
    • Deep neck space infections (e.g., retropharyngeal abscess, peritonsillar abscess, Ludwig's angina)
      • Epiglottitis/bacterial tracheitis
        –Occurs in children ages 2–7 and increasingly in adults
      • Diphtheria
      • Trauma
      • Lymphadenitis (cervical)
      • Cancer (e.g., tonsillar, tongue, laryngeal, esophageal)
      • Caustic ingestions
      • Thyroiditis
      • Angina/acute coronary syndrome

      Workup and Diagnosis

      • History and physical exam often make the diagnosis
        –Consider exposure history, age, associated symptoms, past medical history (e.g. immunocompromise), use of inhaled steroids (e.g. with Candida pharyngitis), allergy history)
        –Focus on head and neck, lung, and abdominal examinations
      • Streptococcal pharyngitis is often a clinical diagnosis
        –Presence of three out of four of the following criteria suggests the diagnosis: Exudative pharyngitis (not just a red throat); tender anterior lymphadenopathy; presence or history of fever; and absence of a cough; whereas if none or one of the criteria exists, group A β-hemolytic streptococcus is unlikely
        –Streptococcal culture is the gold standard (inexpensive; identifies group A and others; 1–2 days for results)
        –Rapid strep testing is more expensive and identifies only group A strep, but gives immediate results; very specific (95%) but less sensitive (60–70%), so consider culture if negative
      • Monospot or CBC showing atypical lymphocytes is diagnostic for mononucleosis
      • X-ray for foreign body; laryngoscopy if unable to verify
      • Lateral neck X-ray may diagnose epiglottitis and retropharyngeal abscess
      • Gonococcal and diphtheria cultures if necessary
      • Barium swallow, upper GI series, or EGD for GERD

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Sore Throat: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Infectious
    –Viral
         –Adenovirus
         –Rhinovirus
         –Parainfluenza
         –Influenza
         –Coronavirus
         –Others: EBV RSV, CMV, HSV
    –Bacterial
         –Streptococcus
         –Haemophilus
         –Moraxella
         –Staphylococcus
         –Corynebacterium
    –Fungal
         –Candida
    • Inflammatory
      –Allergy
      –Gastroesophageal reflux disease
      –Sinusitis resulting in postnasal drainage
      • Tumors
        –Leukemia
        –Rhabdosarcomas
        –Squamous cell carcinoma secondary to oral ulcerations
      • Trauma
        –Foreign body ingestion
        –Caustic ingestion
        –Soft tissue injury from accidental and nonaccidental trauma
    • Systemic/rheumatologic disorders
      –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
      –Behçet syndrome
      –Reiter syndrome
      • Others
        –Cigarette smoke
        –Environmental pollutants
        –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

    Workup and Diagnosis

  • History
    –Duration, onset, severity, frequency, odynophagia, dysphagia, daycare, sick contacts, fever, malaise, headache
    –Foreign body and caustic ingestion
    –Days of school or work missed
    –Immunization history
    –Medical history: Systemic disease, connective tissue disorder
      • Physical exam
        –Nasal exam: Evidence of rhinosinusitis
        –Mouth: Ulcerations, masses, tonsil size, erythema, exudates
        –Neck: Lymphadenopathy
        –Skin: Rash
        –Chest: Wheezes, asymmetry
    • Studies
      –For pharyngitis: A major goal is to differentiate streptococcal pharyngitis from viral etiologies
      –Throat culture: 92% sensitive; 100% specific; requires 24–48 hours
      –Rapid strep test: 72–85% sensitive; 88–100% specific
      –CBC with differential for suspected mononucleosis
      –Chest X-ray (inspiratory and expiratory) for suspected foreign body
      –CT neck: When complication of infection is suspected such as abscess

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    SORE THROAT: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL, U.S.A.) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Mouth lesions: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.

    Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.

    Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Throat pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

    Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Gag reflex abnormalities [Pharyngeal reflex abnormalities]: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient (or a family member if the patient can’t communicate) about the onset and duration of swallowing difficulties, if any. Are liquids more difficult to swallow than solids? Is swallowing more difficult at certain times of the day (as occurs in the bulbar palsy associated with myasthenia gravis)? If the patient also has trouble chewing, suspect more widespread neurologic involvement because chewing involves different CNs.

    Explore the patient’s medical history for vascular and degenerative disorders. Then assess his respiratory status for evidence of aspiration, and perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Acute poststreptococcal glomerulonephritis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis requires a detailed patient history and assessment of clinical symptoms and laboratory tests.

    Urinalysis typically reveals proteinuria and hematuria. RBCs, white blood cells, and mixed cell casts are common in urinary sediment. Elevated serum creatinine levels and low creatinine clearance accompany impaired glomerular filtration. Elevated antistreptolysin-O titers (in 80% of patients), elevated streptozyme and anti-DNase B titers, and low serum complement levels verify recent streptococcal infection. A throat culture may also show group A beta-hemolytic streptococcus. Renal ultrasound may show a normal or slightly enlarged kidney. A renal biopsy may confirm the diagnosis or assess renal tissue status.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Pharyngitis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Physical examination of the pharynx reveals generalized redness and inflammation of the posterior wall, and red, edematous mucous membranes studded with white or yellow follicles. Exudate is usually confined to the lymphoid areas of the throat, sparing the tonsillar pillars. Bacterial pharyngitis usually produces a large amount of exudate.

    A throat culture may be performed to identify bacterial organisms that may be the cause of the inflammation.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Throat abscesses: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis of peritonsillar abscess usually begins with a patient history of bacterial pharyngitis. Examination of the throat shows swelling of the soft palate on the abscessed side, with displacement of the uvula to the opposite side; red, edematous mucous membranes; and tonsil displacement toward the midline. Culture may reveal streptococcal or staphylococcal infection.

    Diagnosis of retropharyngeal abscess is based on patient history of nasopharyngitis or pharyngitis and on physical examination revealing a soft, red bulging of the posterior pharyngeal wall. X-rays show the larynx pushed forward and a widened space between the posterior pharyngeal wall and vertebrae. If neck pain or stiffness occurs, look for extension to the epidural space or the cervical vertebrae. Culture and sensitivity tests isolate the causative organism and reveal the appropriate antibiotic.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Mouth lesions: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.

    Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially any painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.

    Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Throat pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

    Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate; if exudate is present, obtain a specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Gag reflex abnormalities [Pharyngeal reflex abnormalities]: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient (or a family member if the patient can’t communicate) about the onset and duration of swallowing difficulties, if any. Are liquids more difficult to swallow than solids? Is swallowing more difficult at certain times of the day (as occurs in the bulbar palsy associated with myasthenia gravis)? If the patient also has trouble chewing, suspect more widespread neurologic involvement because chewing involves different cranial nerves.

    Explore the patient’s medical history for vascular and degenerative disorders. Then assess his respiratory status for evidence of aspiration, and perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pharyngitis: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    Is there any history of seasonal allergies, trauma, malignancy, radiation therapy, inhalation, ingestion, thyroid dysfunction, or significant psychiatric illness? If so, then the possibility of a noninfectious cause of ST exists. How severe is the ST and how abrupt was the onset? Is there accompanying rhinitis, nasal congestion, cough, malaise, myalgias, rash, diarrhea, conjunctivitis, fever, tender or swollen “neck glands,” pain on swallowing, headache, nausea, vomiting, or abdominal pain? Classically, GABHS pharyngitis is severe and of acute ( <1 day) onset and accompanied by fever (temperature >101°F), painful swallowing, tender anterior cervical adenopathy and myalgias, but not cough or rhinitis. Headache, nausea, vomiting, and abdominal pain may be seen as well, especially in children. Conversely, the gradual onset of mild ST accompanied by rhinorrhea, cough, hoarseness, conjunctivitis, or diarrhea in an afebrile patient speaks strongly for a viral cause. Despite these broad generalizations, classic symptom complexes alone are neither sensitive nor specific enough to rely on for judging the need for antibacterial treatment (2–5). For example, the symptoms most likely to predict the presence of GABHS infection—fever and lack of cough—have sensitivities of 0.58 to 0.72 and specificities of only 0.43 to 0.67 (2). Additionally, the presence of a positive throat culture in the prior year or recent exposure to GABHS has high specificity, 0.90, but low sensitivity, 0.23 (2,3).

    Physical examination

     A. Focused physical examination (PE). This should include assessing vital signs (especially temperature) and examining the head, eyes, ears, nose, throat, neck, and skin. Findings classically associated with GABHS infection include palatal petechiae, intense (“beefy red”) tonsillopharyngeal erythema with exudates, tender anterior cervical adenopathy, and a scarlatiniform rash (Chapter 13.5). Conversely, absence of these features together with the presence of rhinitis, hoarseness, conjunctivitis, stomatitis, discrete ulcerative lesions, or a typical viral exanthem point toward a viral cause. In IM, the classic GABHS features are often combined with posterior cervical or generalized lymphadenopathy and hepatosplenomegaly. However, once again none of these physical findings in and of themselves have sufficiently high sensitivity and specificity to rely on for accurate diagnosis (2–4).

     B. Additional PE. Abdominal examination is dictated by either gastrointestinal symptoms or the presence of severe fatigue with posterior cervical adenopathy (suggesting IM). Cough or fever should lead to pulmonary examination. Cardiac examination is important for toxic appearing patients. >

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Sore Throat: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Rhinovirus

    ❑ Group A streptococci

    ❑ Ebstein-Barr virus

    ❑ Adenovirus

    ❑ Influenza

    ❑ Candida/thrush

    ❑ Herpes simplex virus

    ❑ Peritonsillar abscess

    ❑ Mycoplasma pneumoniae

    ❑ Coxsackievirus

    ❑ Primary HIV

    ❑ Neisseria gonorrhea

    ❑ Epiglottitis

    ❑ Corynebacterium diphtheriae

    ❑ Leukemia

    Diagnostic Approach

    The most important consideration is whether the patient has a group A strep infection because prompt treatment prevents rheumatic fever. The findings of fever, tender anterior cervical adenopathy, and tonsillar exudate can be combined to make the diagnosis more or less likely. Rapid antigen tests have a sensitivity of 80% to 90% and specificity of 95% to 100%, so give a reasonably accurate diagnosis. Because of limitations in sensitivity however, patients with a high suspicion on clinical grounds should have a backup culture taken.

     Prior probability in an adult population with sore throat is 5% to 10%, and in a pediatric population 20% to 25%. A prominent sore throat out of proportion to the degree of pharyngeal inflammation should raise the possibility of acute epiglottitis and acutely impending airway compromise. Persistent unilateral tonsillar enlargement in a young adult without sore throat should raise the suspicion of lymphoma.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Glomerulo-nephritis, acute poststreptococcal: Diagnosis
    (Handbook of Diseases)

    A detailed patient history, assessment of clinical symptoms, and laboratory tests are needed to diagnose this disease. The following tests support the diagnosis:

    ❑ Urinalysis typically reveals proteinuria and hematuria. RBCs, white blood cells, and mixed cell casts are common findings in urinary sediment.

    ❑ Blood tests show elevated serum creatinine levels, low creatinine clearance, and impaired glomerular filtration.

    ❑ Elevated antistreptolysin-O titers (in 80% of patients), elevated streptozyme and anti-DNase B titers, and low serum complement levels verify recent streptococcal infection.

    ❑ Throat culture may also show group A beta-hemolytic streptococci.

    ❑ Renal ultrasonography may show a normal or slightly enlarged kidney.

    ❑ Renal biopsy may confirm the diagnosis in a patient with APSGN or may be used to assess renal tissue status.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Pharyngitis: Diagnosis
    (Handbook of Diseases)

    Physical examination of the pharynx reveals generalized redness and inflammation of the posterior wall and red, edematous mucous membranes studded with white or yellow follicles. Exudate is usually confined to the lymphoid areas of the throat, sparing the tonsillar pillars. Bacterial pharyngitis usually produces a large amount of exudate.

    A throat culture may be performed to identify bacterial organisms that may be the cause of the inflammation.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Mouth lesions: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Throat pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Sore Throat: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Infection

    Pharyngitis/Tonsillitis

    Viral

  • Severalviruses may cause pharyngitis/tonsillitis, including parainfluenzaviruses, influenza viruses, rhinoviruses, coronaviruses, and respiratorysyncytial virus. Coryza and cough predominate, whereas fever isvariable finding. Nasal wash cultures are diagnostic but usuallyunnecessary for management.
  • Enteroviruses also may cause sore throatand fever, especially in summer months, but tonsillar exudate isunusual.

  • Herpanginais characterized by fever and painful vesicular lesions on pharynxand tonsils.
  • Coxsackie A16 is major cause of hand-foot-mouthdisease, which is characterized by vesicular lesions in the mouthand on hands and feet.
  • Herpes simplex virus produces acutegingivostomatitis with fever and painful vesicles usually confinedto anterior mouth. However, lesions may extend to anterior tonsillarpillars.
  • Epstein-Barr virus is common causeof sore throat in adolescents. Other characteristic findings ofinfectious mononucleosis include fever, malaise, fatigue, cervicalor generalized lymphadenopathy, and hepatosplenomegaly. >10% atypicallymphocytes are usually seen on blood smear. Positive mono spottest, which identifies immunoglobulin M (IgM) heterophile antibody,is diagnostic. When this test is negative, IgG and IgM antibodyagainst viral capsid antigen (VCA) should be determined. Presenceof IgM-VCA is associated with recent or current illness and confirmsdiagnosis, whereas IgG-VCA is present continuously after acute infection.
  • Adenovirus may cause pharyngoconjunctivalfever. Follicular hyperplasia of tonsils and exudate may be seen.

    • Bacterial

    Group A Streptococcus

  • Most commonbacterial cause of pharyngitis/tonsillitis is group A Streptococcus.
  • Classic clinical presentation is school-agedchild with acute onset of fever and sore throat. Headache, abdominalpain, and vomiting also may occur. Rhinorrhea, cough, conjunctivitis,hoarseness, and diarrhea are unusual. Tonsils are enlarged and inflamed,with patches of exudate. Petechiae may sometimes be seen on palate.
  • Anterior cervical lymph nodes may beenlarged on 1 or both sides and are often tender.
  • Usual clinical dilemma is to distinguishbetween viral infection or group A streptococcal infection. Difficultto distinguish them clinically, except when typical erythematoussandpaper-like rash of scarlet fever occurs, which signifies infectionwith group A Streptococcus.
  • Rapid techniques are now availablefor detection of streptococcal antigen. Either rapid antigen testor throat culture should be performed if streptococcal pharyngitisis suspected. If antigen assay is negative, throat culture shouldbe obtained.

    • Other Bacteria

  • Pharyngitiscaused by group C or G Streptococcus is indistinguishable from that causedby group A Streptococcus.
  • A. hemolyticum produces illness similarto group A Streptococcus. Scarlet fever–like rash occursmost often in adolescents, but strawberry tongue and palatal petechiaehave not been described.
  • N. gonorrhoeae pharyngitis can occurin sexually active adolescents as consequence of oral-genital contact.Ulceration of pharynx and tonsils along with exudate may be seen.Its presence in younger children suggests sexual abuse.
  • M. pneumoniae is uncommon cause ofpharyngitis, whereas C. diphtheriae is rare cause of pharyngitis.With the latter infection, acute onset of fever and sore throatis followed in 1–2 days by grayish membrane over pharynxand tonsils, which may extend into larynx and trachea.
  • Positive throat culture confirms diagnosisof these pathogens.

    • Peritonsillar, Retropharyngeal, and Lateral Pharyngeal Abscesses

  • Generallydue to spread of infection from local sites.
  • Most common pathogens are aerobes (groupA Streptococcus, S. aureus, H. influenzae) and anaerobes (Peptostreptococcus,Fusobacterium, Prevotella, Porphyromonas species), although manyinfections are polymicrobial.
  • Peritonsillar abscess generally occursas complication of acute bacterial tonsillitis in older childrenand adolescents. Sore throat, fever, pain on swallowing, drooling,and trismus characterize this infection. Ipsilateral otalgia alsomay occur. Swollen inflamed tonsil has fluctuant quality and oftenpushes uvula across midline of oral cavity. Diagnosis is clinical,although specific pathogen can be cultured from infected tonsilor abscess drainage.
  • Although retropharyngeal abscess/cellulitisis uncommon cause of sore throat, it usually occurs in children <4yrs. Most children appear toxic and are in respiratory distress,but some complain of sore throat and painful swallowing early incourse. Often direct visualization is impossible and lateral neck radiographyshows bulge of posterior pharyngeal wall. If diagnosis is uncertain,CT can be performed.
  • Lateral pharyngeal abscess usuallypresents with fever and trismus as well as swelling and tendernessbelow mandible. CT is helpful in determining extent of abscess.

    • Irritants

  • Upon awakeningin morning, otherwise well child may have scratchy sore throat, whichusually improves over several hours. This sensation is usually dueto dryness of pharynx and frequently occurs with rhinitis, especiallyduring winter months when humidity is low and mouth breathing islikely because of nasal congestion.
  • Exposure to dust or smoke also maycause irritation of pharynx.
  • Postnasal drip secondary to allergicrhinitis or sinusitis also may cause pharyngeal irritation and mildsore throat.

    • Trauma

  • Excessiveuse of voice due to prolonged shouting or singing may cause sore throat.
  • Burn secondary to exposure of hot gasesor liquid also may cause pharyngeal pain.

    • Foreign Body

  • Foreignbody lodged in pharynx causes acute onset of choking, dysphagia,and sometimes upper airway obstruction.
  • Commonly, fish bone or chicken bonecan be seen in pharynx. Otherwise, neck radiography may be diagnostic.
  • Only symptom of retained foreign bodyin upper airway may be persistent stridor. In this circumstance,laryngoscopy is usually diagnostic.

    • Caustic Substances

  • Ingestionof caustic substances may cause inflammation of pharynx.
  • History and physical exam are diagnostic.
  • For suspected esophageal injury, esophagoscopyshould be performed.

    • Psychogenic

    Sometimes there does not seem to be explanationfor sore throat after history, physical exam, negative throat culture,and normal neck radiographs. In this case, psychosocial historyis most valuable clinical tool.

    Diagnostic Approach

  • Historyand physical exam provide important clues for proper diagnosis ofsore throat.
  • Most common clinical dilemma in childwith pharyngitis is whether pathogen is virus or group A Streptococcus.Tests to detect streptococcal antigen may be diagnostic, but ifresults of such tests are negative, throat culture should be performed.
  • Because many cases of pharyngitis aredue to viruses, antibiotic use should be guided by antigen detectiontests or culture. Presence of conjunctivitis, cough, rhinitis, andhoarseness suggests viral etiology. Infectious mononucleosis isalso a consideration, especially in older children and adolescents.
  • Neck radiography, flexible laryngoscopy,and CT are useful with suspected foreign body or retropharyngeal/lateralpharyngeal abscess.
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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Mouth lesions: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed odor or drainage or experienced pain. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.

    Next, perform a complete oral examination, noting lesion sites and character. Examine the patient's lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums. Note any odor.

    Palpate the neck for adenopathy, especially in patients who use tobacco or ingest alcohol excessively.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Throat pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? How was it treated? Is it accompanied by fever, ear pain, or dysphagia? Review the patient's medical history for throat problems, allergies, and systemic disorders.

    Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx and the nasopharynx. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose. Also, check the patient's ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Gag reflex abnormalities [Pharyngeal reflex abnormalities]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient (or a family member if the patient can't communicate) about the onset and duration of swallowing difficulties, if any. Are liquids more difficult to swallow than solids? Is swallowing more difficult at certain times of the day (as occurs in the bulbar palsy associated with myasthenia gravis)? If the patient also has trouble chewing, suspect more widespread neurologic involvement because chewing involves different CNs.

    Explore the patient's medical history for vascular and degenerative disorders. Then assess his respiratory status for evidence of aspiration, and perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    SORE THROAT: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and to start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Pharyngitis: Pharyngitis - DIAGNOSIS
    (The 5-Minute Pediatric Consult)

    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.
    >

    » READ BOOK EXCERPT ONLINE »

    Source: The 5-Minute Pediatric Consult, 2008


     » Next page: Signs of Strep throat

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