Pharyngitis, Emergency Medicine

Basics

Description

Inflammation/infection of the pharynx
3rd most common complaint for physician visits
30 million cases diagnosed annually
Group A ²-hemolytic streptococcus (GAS):
- Streptococcus pyogenes
- Unusual in children <3 yr old
- Cause of 20 " 30% of childhood pharyngitis
- Bimodal incidence, highest in ages 5 " 7 and 12 " 13 yr
- Cause of 5 " 15% of adult pharyngitis
- Peak months: January " May; also at the start of the school year

Etiology

Viral (most common infectious cause):
- Rhinovirus (20%)
- Coronavirus (>5%)
- Adenovirus (5%)
- Herpes simplex virus (4%)
- Parainfluenza virus (2%)
- Influenza virus (2%)
- Coxsackievirus (<1%)
- Epstein " Barr virus (<1%)
- Acute human immunodeficiency virus (HIV)
Bacterial:
- GAS (S. pyogenes [15 " 30%])
- Fusobacterium necrophorum (10%)
- Group C & G ²-hemolytic streptococcus (5%)
- Neisseria gonorrhea (<1%)
- Corynebacterium diphtheriae (<1%)
- Arcanobacterium haemolyticum (<1%)
- Chlamydia pneumoniae
- Mycoplasma pneumoniae (<1%)
- Syphilis
- Tuberculosis
Fungal:
- Candida (thrush)
Chemical burns
Foreign bodies
Inhalants
Postnasal drip
Malignancy
GERD

Diagnosis

Signs and Symptoms

History

Viral:
- Cough
- Rhinorrhea
- Sore throat usually follows
- Have a high suspicion for acute HIV in at-risk patients presenting with persistent pharyngitis despite treatment
Bacterial:
- Sudden-onset sore throat that usually precedes other symptoms
- Odynophagia
- Fever
- Headache
- Abdominal pain
- Nausea and vomiting
- Uncharacteristic symptoms:
  - Coryza
  - Hoarseness
  - Diarrhea

Physical Exam

High-risk features for a serious complication of pharyngitis:
- Stridor, respiratory distress
- Drooling
- Dysphonia
- Marked neck swelling
- Neurologic dysfunction
Viral:
- Cough
- Coryza
- Rhinorrhea
- Pharyngeal erythema
- Gingivostomatitis
GAS:
- Tonsillopharyngeal erythema/exudates
- Soft palatal petechiae
- Beefy red, swollen uvula
- Anterior cervical lymphadenopathy
- Scarlatiniform rash
- Uncharacteristic signs:
  - Conjunctivitis
  - Anterior stomatitis
  - Discrete ulcerative lesions
Mononucleosis:
- Mistaken for GAS due to similar presentation:
  - Exudative pharyngitis
  - Tender cervical lymphadenopathy
  - Fever
  - Rash
- Other possible exam findings:
  - Hepatosplenomegaly
  - Jaundice
Diphtheria:
- Consider in nonimmunized patients
- Airway-threatening gray pharyngeal membrane
- Myocarditis (2/3 of patients); clinically evident cardiac dysfunction (10 " 25%)
- Cranial and peripheral neuropathies (5%)
Gonococcal pharyngitis:
- Can be asymptomatic
- Always evaluate children for sexual abuse
- Recurrent episodes of pharyngitis

Essential Workup

Modified Center criteria for the diagnosis of GAS pharyngitis (most widely used decision rule):

Criteria (points):
- Absence of cough (+1)
- Tonsillar exudates or swelling (+1)
- Swollen and tender anterior cervical nodes (+1)
- Temperature >38 ΊC (+1)
- Age in years:
  - 3 " 14 (+1)
  - 15 " 44 (0)
  - >45 ( " 1)
Scoring:
- <1 should not be tested or treated
- 3 is associated with a risk of 28 " 35%
- >4 is associated with a risk of 51 " 53%
Patients with 3 criteria should receive a rapid antigen detection test (RADT)
Presumptive treatment without testing has led to inappropriate use of antibiotics in about 50% of cases
Some suggest that patients with a score >4 should be treated empirically without a RADT

Diagnosis Tests & Interpretation

Lab

Throat culture:
- Gold standard
- 24 " 48 hr for results, will delay treatment
- Necessitates contacting patient/family
- Obtain when Gonococcus is suspected
GAS RADT:
- Results are available within 30 min
- Treat all patients with (+) RADT results
- Technique: Performed by swabbing the tonsils or posterior pharynx:
  - Avoid contact with the tongue, buccal mucosa, and lips
- Sensitivity 85 " 95%
- Specificity 96 " 99%:
  - Confirm with conventional throat culture in children/adolescents with negative RADT
  - Optical immunoassay is extremely accurate; negative results do not require confirmatory culture
Monospot:
- Detects heterophil antibody:
  - Sensitivity:
    - <2 yr old: <30%
    - 2 " 4 yr old: 75%
    - >5 yr old: 90%
- CBC with peripheral smear: 50% lymphocytes, 10% atypical lymphocytes
- Obtain rapid viral loads if HIV is suspected

Imaging

Lateral neck radiograph for suspected epiglottitis, retropharyngeal abscess, or foreign body
Contrast-enhanced CT of the neck is useful to identify complications such as peritonsilar abscess and retropharyngeal abscess

Differential Diagnosis

Epiglottitis
Peritonsillar/retropharyngeal abscess
Diphtheria
Mononucleosis
Lemierre disease
Ludwig angina
Candida infection
Gonorrhea
Acute HIV infection
Acute leukemia/lymphoma
Oropharyngeal cancer
Foreign body
Inhalants and chemical burns
Postnasal drip
GERD

Treatment

Pre-Hospital

Observe/manage airway for respiratory distress
Normal saline (NS) hydration for hypotension/dehydration

Initial Stabilization/Therapy

ABCs
Fluid resuscitation: 1 L (peds: 20 mL/kg) NS bolus for signs of volume depletion or if patient is unable to tolerate oral solutions

Ed Treatment/Procedures

Antipyretics/analgesics:
- Acetaminophen
- Ibuprofen
- Topical analgesics (e.g., Chloraseptic spray)
GAS infection:
- Often mild and self-limited:
  - Antibiotic therapy accelerates symptom relief (fever and pain) by 1 " 2 days
- Goal of antibiotic treatment is to reduce the incidence of acute rheumatic fever, symptoms, and suppurative complications
Antibiotics:
- Penicillin V: Antibiotic of choice for GAS pharyngitis
- Cephalosporins or macrolides are an acceptable alternative treatment for nonresponders and penicillin-allergic patients
Corticosteroids:
- In conjunction with antibiotics, corticosteroids have a 3-fold increase in the likelihood of symptom resolution at 24 hr
- Number needed to treat: 3.3 " 3.7
- Avoid in diabetics and immunocompromised patients
Potential complications of streptococcal infection:
- Suppurative complications:
  - Peritonsillar/retropharyngeal abscess
  - Lemierre disease
  - Otitis media/mastoiditis
- Nonsuppurative complications:
  - Acute rheumatic fever:
    - Rare in industrialized countries, but still the leading cause of cardiac death within 1st 5 decades of life
    - Sequelae of GAS; not proven in association with group C or G
  - Acute poststreptococcal glomerulonephritis
  - Sydenham chorea
  - Reactive arthritis
  - PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection:
    - Sudden onset of symptoms similar to obsessive " compulsive disorder
    - Caused by an autoimmune reaction affecting the basal ganglia
    - Uncommon and controversial
Diphtheria:
- Goals of therapy:
  - Prevent airway obstruction
  - Treat infection
- Penicillin or macrolide antibiotic
- Complications:
  - Exotoxin-mediated myocarditis and neuritis (cranial neuropathies)
Gonococcal pharyngitis:
- 3rd-generation cephalosporin plus macrolide for possible Chlamydia coinfection

Medication

First Line

Penicillin G:
- <27 kg: Benzathine penicillin G (Bicillin LA): 0.6 million U IM 1
- >27 kg: Benzathine penicillin G (Bicillin LA): 1.2 million U IM 1
Penicillin V:
- <12 yr: 25 " 50 mg/kg/d PO div. q6 " 8h 10 days
- >12 yr: 250 " 500 mg PO q6 " 8h 10 days
Amoxicillin:
- 50 mg/kg PO QD, (max. 1 g) 10 days

Second Line

Macrolides:
- Azithromycin: 20 mg/kg/d 3 days (max. 500 mg per dose)
- Erythromycin: 40 " 50 mg/kg PO div. q6h 10 days (max. 500 mg per dose)
Oral cephalosporins:
- Cephalexin: 20 mg/kg/dose PO BID 5 days (max. 500 mg per dose)
Steroids:
- Dexamethasone: 0.6 mg/kg IM/PO 1 (max. 10 mg)
- Prednisone: 40 " 60 mg PO 1
Special conditions:
- Suspected gonococcal pharyngitis:
  - Ceftriaxone: 125 " 250 mg IM 1

Follow-Up

Disposition

Admission Criteria

Airway compromise
Severe dehydration
Suspected child abuse

Discharge Criteria
Able to tolerate oral intake

Follow-Up Recommendations

If symptoms do not improve within 72 hr
Patients are no longer contagious after 24 hr of antibiotic treatment
Mononucleosis patients should avoid contact sports

Pearls and Pitfalls

Use the modified Centor criteria to make the decision to test for GAS pharyngitis
Children with negative RADT need follow-up throat culture
Acute rheumatic fever is a more common complication of GAS pharyngitis in nonindustrialized nations
Evaluate for high-risk complications of bacterial pharyngitis (e.g., peritonsillar abscess, retropharyngeal abscess, Lemierre disease)

Additional Reading

Hayward G, Thompson M, Heneghan C, et al. Corticosteroids for pain relief in sore throat: Systemic review and meta-analysis. BMJ. 2009;339:b2976.
Kociolek LK, Shulman ST. In the clinic. Pharyngitis. Ann Intern Med. 2012;157:ITC3-1 " ITC3-16.
McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004;291:1587 " 1595.
Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med. 2011;364:648 " 655.

Codes

ICD9

034.0 Streptococcal sore throat
054.79 Herpes simplex with other specified complications
462 Acute pharyngitis
487.1 Influenza with other respiratory manifestations

ICD10

J02.0 Streptococcal pharyngitis
J02.8 Acute pharyngitis due to other specified organisms
J02.9 Acute pharyngitis, unspecified
B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis
J02 Acute pharyngitis
J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations

SNOMED

405737000 Pharyngitis (disorder)
43878008 Streptococcal sore throat (disorder)
232399005 Acute herpes simplex pharyngitis (disorder)
195924009 Influenza with pharyngitis (disorder)
78430008 Adenoviral pharyngitis (disorder)

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