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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

- Viral: - Cough - Rhinorrhea - Sore throat usually follows - Have a high suspicion for acute HIV in at-risk patients presenting with persistent pharyngitis despite treatment

- Mononucleosis: - Mistaken for GAS due to similar presentation: - Exudative pharyngitis - Tender cervical lymphadenopathy - Fever - Rash

- Other possible exam findings: - Hepatosplenomegaly - Jaundice

- Gonococcal pharyngitis: - Can be asymptomatic - Always evaluate children for sexual abuse - Recurrent episodes of pharyngitis

- 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

- Antipyretics/analgesics: - Acetaminophen - Ibuprofen - Topical analgesics (e.g., Chloraseptic spray)

- 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

  • Inflammation/infection of the pharynx
  • 3rd most common complaint for physician visits
  • 30 million cases diagnosed annually
  • Group A ²-hemolytic streptococcus (GAS):Streptococcus pyogenesUnusual in children <3 yr oldCause of 20 " 30% of childhood pharyngitisBimodal incidence, highest in ages 5 " 7 and 12 " 13 yrCause of 5 " 15% of adult pharyngitisPeak 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 pneumoniaeMycoplasma pneumoniae (<1%)SyphilisTuberculosis
  • Fungal:
  • Chemical burns
  • Foreign bodies
  • Inhalants
  • Postnasal drip
  • Malignancy
  • GERD

Diagnosis

Signs and Symptoms

History

  • Viral:CoughRhinorrheaSore throat usually followsHave 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 symptomsOdynophagiaFeverHeadacheAbdominal painNausea and vomitingUncharacteristic symptoms:

Physical Exam

  • High-risk features for a serious complication of pharyngitis:Stridor, respiratory distressDroolingDysphoniaMarked neck swellingNeurologic dysfunction
  • Viral:CoughCoryzaRhinorrheaPharyngeal erythemaGingivostomatitis
  • GAS:Tonsillopharyngeal erythema/exudatesSoft palatal petechiaeBeefy red, swollen uvulaAnterior cervical lymphadenopathyScarlatiniform rashUncharacteristic signs:ConjunctivitisAnterior stomatitisDiscrete ulcerative lesions
  • Mononucleosis:Mistaken for GAS due to similar presentation:Exudative pharyngitisTender cervical lymphadenopathyFeverRashOther possible exam findings:HepatosplenomegalyJaundice
  • Diphtheria:Consider in nonimmunized patientsAirway-threatening gray pharyngeal membraneMyocarditis (2/3 of patients); clinically evident cardiac dysfunction (10 " 25%)Cranial and peripheral neuropathies (5%)
  • Gonococcal pharyngitis:Can be asymptomaticAlways evaluate children for sexual abuseRecurrent 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 treated3 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 standard24 " 48 hr for results, will delay treatmentNecessitates contacting patient/familyObtain when Gonococcus is suspected
  • GAS RADT:Results are available within 30 minTreat all patients with (+) RADT resultsTechnique: Performed by swabbing the tonsils or posterior pharynx:Avoid contact with the tongue, buccal mucosa, and lipsSensitivity 85 " 95%Specificity 96 " 99%:Confirm with conventional throat culture in children/adolescents with negative RADTOptical 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 lymphocytesObtain 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:AcetaminophenIbuprofenTopical analgesics (e.g., Chloraseptic spray)
  • GAS infection:Often mild and self-limited:Antibiotic therapy accelerates symptom relief (fever and pain) by 1 " 2 daysGoal of antibiotic treatment is to reduce the incidence of acute rheumatic fever, symptoms, and suppurative complications
  • Antibiotics:Penicillin V: Antibiotic of choice for GAS pharyngitisCephalosporins 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 hrNumber needed to treat: 3.3 " 3.7Avoid in diabetics and immunocompromised patients
  • Potential complications of streptococcal infection:Suppurative complications:Peritonsillar/retropharyngeal abscessLemierre diseaseOtitis media/mastoiditisNonsuppurative complications:Acute rheumatic fever:Rare in industrialized countries, but still the leading cause of cardiac death within 1st 5 decades of lifeSequelae of GAS; not proven in association with group C or GAcute poststreptococcal glomerulonephritisSydenham choreaReactive arthritisPANDAS: Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection:Sudden onset of symptoms similar to obsessive " compulsive disorderCaused by an autoimmune reaction affecting the basal gangliaUncommon and controversial
  • Diphtheria:Goals of therapy:Prevent airway obstructionTreat infectionPenicillin or macrolide antibioticComplications: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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Epiglottitis
  • Mononucleosis
  • Peritonsillar Abscess
  • Retropharyngeal Abscess
  • Rheumatic Fever

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)