Pharyngitis: Cause, Symptoms, Signs, Complications, Differential diagnosis, Investigations, Treatment, Prevention

Pharyngitis, Strep Throat

Pharyngitis

Pharyngitis Causes:

Group A beta-hemolytic streptococci (S pyogenes)- most common bacterial cause of pharyngitis.

Transmission- by droplets of infected secretions.

Group A streptococci- producing erythrogenic toxin may produce scarlet fever in susceptible persons.

Pharyngitis Symptoms and Signs:

“Strep throat”- Abrupt onset of fever, sore throat, pain on swallowing, malaise, nausea, & tender cervical adenopathy.

Soft palate, pharynx, and tonsils are red and edematous.

May be purulent exudate.

Centor clinical criteria for diagnosis of streptococcal pharyngitis-

temperature greater than 38°C,

tender anterior cervical adenopathy,

lack of a cough, and

pharyngotonsillar exudate.

Rash of scarlet fever (scarletina)- diffusely erythematous & resembles sunburn.

Superimposed fine red papules give skin sandpaper consistency; most intense in groin & axillas.

Blanches on pressure, may become petechial, fades in 2–5 days, leaving fine desquamation.

Face is flushed, with circumoral pallor, & (strawberry tongue) tongue coated with enlarged red papillae.

Pharyngitis Laboratory Findings:

Leukocytosis with neutrophil predominance.

Throat culture- sensitivity of 80–90%.

Rapid diagnostic tests- streptococcal antigen detection, are slightly less sensitive than culture.

Centor criteria, for identifying which patients rapid antigen test or throat culture needed.

Who meet two or more criteria merit further testing.

When three of the four criteria present, laboratory sensitivity of rapid antigen testing exceeds 90%.

When only one present, streptococcal pharyngitis is unlikely.

Pharyngitis Complications:

Suppurative complications- sinusitis, otitis media, peritonsillar abscess, mastoiditis, & cervical lymphadenitis.

Nonsuppurative complications- rheumatic fever & glomerulonephritis.

more common in children.

Pharyngitis Differential Diagnosis:

Streptococcal sore throat resembles- pharyngitis caused by viruses adenoviruses, Epstein Barr virus, or bacteria- Fusobacterium necrophorum & Arcanobacterium haemolyticum (may cause rash).

Acute HIV infection- Pharyngitis and lymphadenopathy common.

Generalized lymphadenopathy, atypical lymphocytosis, splenomegaly, and a positive serologic test distinguish mononucleosis from streptococcal pharyngitis.

Diphtheria- pseudomembrane seen.

oropharyngeal candidiasis- white patches of exudate & less erythema.

(Vincent fusospirochetal gingivitis or stomatitis) Necrotizing ulcerative gingivostomatitis- presents with a shallow ulcers in mouth.

Chlamydia trachomatis, Neisseria gonorrhoeae, and primary herpes simplex virus- in those with risk factors.

Retropharyngeal abscess or bacterial epiglottitis- when odynophagia and difficulty in handling secretions, & severity of symptoms disproportionate to the findings on examination of pharynx.

F necrophorum causes pharyngitis similar as group A beta hemolytic streptococci in young adults & adolescents, & is associated with suppurative thrombophlebitis of internal jugular vein (Lemierre syndrome), metastatic infections & bacteremia.

Pharyngitis Treatment:

Antimicrobial therapy for resolution of symptoms & prevention of complications.

Inj. Benzathine penicillin G, 1.2 million units IM as a single dose. or

T. Penicillin VK, 250 mg 4 times daily or 500 mg twice daily for 10 days. or

C. Amoxicillin 1000 mg once daily or 500 mg twice daily for 10 days.

Cephalosporins:

should be reserved for patients allergic to penicillin, who do not have immediate-type hypersensitivity.

T. Cephalexin 500 mg twice daily for 10 days, or

C. Cefdinir 300 mg twice daily for 5–10 days or 600 mg once daily for 10 days. or

T. Cefadroxil 1000 mg once daily for 10 days, or

T. Cefpodoxime 100 mg twice daily for 5– 10 days,

Macrolides are less effective than penicillins, alternative for the penicillin-allergic patient & considered second-line agents:

T. Erythromycin, 500 mg four times a day, or

T. Azithromycin, 500 mg once daily for 5 days,

Macrolide-resistant strains almost always are susceptible to T. clindamycin 300 mg three times daily, a suitable alternative to penicillins; a 10-day course is effective.

Prevention of Recurrent Rheumatic Fever:

Patients who have had rheumatic fever, treat with continuous course of antimicrobial prophylaxis at least 5 years.

Effective regimens are T. Erythromycin, 250 mg twice daily, or T. Penicillin G, 500 mg daily.

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