pharyngitis

Sayed Mostafa Hashemi MD

2
 INTRODUCTION
 Pharyngitis is defined as inflammation of
the pharynx.
 The anatomic region of the pharynx
invariably affected in adults is the
oropharynx.
 The predominant symptom is sore throat,
which overall is the third most common
chief complaint to physicians in an office-
based practice.
3
4
 Pharyngitis
 Pharyngeal mucosa exhibits an inflammatory
response to many other agents
 Opportunistic bacteria
 Fungi
 Environmental pollutants
 Neoplasm
 Granulomatous disease
 Chemical and physical irritants

5
 Important disease mimic
Pharyngitis
 Scc of the upper aerodigestive tract frequently presents
with a history of chronic sore throat.
 Epiglottitis in adults commonly presents as a severe
acute sore throat and odynophagia with a relatively
normal oropharyngeal examination.
 postnasal drip and laryngopharyngeal reflux can cause
an irritative pharyngitis.
 Occupational and environmental exposures can also be
associated with an irritative pharyngitis and this has
been demonstrated in many different populations, such
as in the firefighters who have World Trade Center
cough
6
Infectious causes of
pharyngitis

7
 Bacterial infection

 Pharyngitis in adults is caused by a

bacterial infection in approximately 5% to
10% of patients This is different than in
children, where bacterial pharyngitis
accounts for 30% to 40% of cases

8
 Bacterial infection

 Approximately 75% of adults presenting

with a sore throat are prescribed
antibiotics for a presumed bacterial
pharyngitis even though this practice will
only help a minority of the patients

9
 BASIC KWNOLAGE ABOUT GABHS
 GABHS is the pathogenic organism responsible for
most cases of bacterial pharyngitis in adults.
 This organism is a gram positive cocci that
grows in chains. Its natural reservoir is the
skin and upper aerodigestive tract mucosa
of the nasopharynx and oropharynx.
 The organism is a pathogen only in humans. Less
than 5% of adults are asymptomatic carriers
 Spread occurs mostly through aerosolized
microdroplets, less commonly by direct contact,
and rarely through ingestion of contaminated non-
pasteurized milk or food.
 Infections are more common in the autumn and
winter
10
 Symptoms & Signs
 Symptoms are usually rapid in onset and include
severe sore throat, odynophagia, cervical
lymphadenopathy, fevers, chills, malaise,
headache, mild neck stiffness, and anorexia.

11
Group A Streptococcus

12
13
Group A Streptococcus

14
 Clinical course
 Untreated; self-limited and consist of localized
inflammation that resolves after 3 to 7 days.
 Patients are contagious during the acute illness and for
approximately 1 week afterward.
 Prompt antibiotic treatment reduces the duration of
symptoms (if treatment begins within 24 to 48 hours of
symptom onset), reduces the period of contagiousness
to 24 hours after beginning treatment, and likely
decreases the incidence of suppurative complications.
 Prevention of rheumatic fever is possible if antibiotic
therapy is started up to 10 days after the onset of
symptoms.

15
 Clinical diagnosis

 high probability :empiric antibiotic

therapy,
 intermediate probability: further
testing ( rapid antigen test) or (throat
culture)
 low probability: symptomatic therapy
and appropriate follow-up

16
 Diagnosis

 Scoring of clinical findings

 Rapid antigen detecting test
 Culture
 Aso

17
 Scoring of clinical findings
centor scoring

 Exsudative tonsilltis
 Absence of cough

 Anterior cervical adenopathy

 Fever(>38.8)

18
 Scoring of clinical findings
centor scoring
 Present of 3or4 indicate positive value in
40-60%
 Absence of 3or4 negative predictive value
in 80%
 Antibiotics prescribed in 4 and 2or3 should
be take rapid test
 Culture?

19
 These scoring systems should not
be used in
 patients who are immunocompromised,
have complicated comorbidities, or have a
history of rheumatic fever.
 during an epidemic of acute rheumatic
fever, in parents with school-aged
children, or for adults with occupations
that bring them into frequent contact with
children
20
 Throat culture

 Strp carrier
 18-24 hour wast of time

21
 Medical Management

 Acute tonsillitis usually subside in 6 day

 PCN is first line(no clinical isolate of
GABHS has ever been documented to
be resistat to penicillin)

22
 treatment
 The oral course should be for 10 days.
Benzathine penicillin can be alternatively used as
a single intramuscular injection that provides
bactericidal levels for 21 to 28 days.
Erythromycin is an acceptable alternative for
patients allergic to penicillin, but isolated reports
of macrolide resistance (<5% of clinical isolates)
have been reported in the United States.
 Clindamycin is an acceptable alternative for
patients with both a penicillin allergy and a
strain resistant to macrolides
23
 Medical Management

 Recurrent or unresponsive infections

require treatment with beta-lactamase
resistant antibiotics such as
 Clindamycin
 Augmentin

 Penicillin plus rifampin

Adenotonsillar hyperplasia may respond to one

month of therapy with beta-lactamase
resistant antibiotics
24
 Medical Management
 Whether treatment is prescribed in all
cases or just in select cases has been
debated.
 It has been suggested that clinicians
should consider treating patients who do
not respond to symptomatic therapy or
patients who are at increased risk for
sequelae.23
 Penicillin and clindamycin both provide
effective treatment when necessary 25
 Complications of Tonsillitis
Nonsuppurative
 Scarlet fever
 Rheumatic fever
 Post streptococal glomerulnephritis
Suppurative
 Peritonsillar Infections
 Parapharyngeal Space Abscess
 Retropharyngeal Space Infections
 Recurrent Acute Tonsillitis

 Same signs and symptoms as acute

 Occurring in 7 separate episodes per year
 5 episodes per year for 2 years
 3 episodes per year for 3 years

M HASEMI MD 27
NON–GROUP A β-HEMOLYTIC
STREPTOCOCCAL INFECTIONS
 Pharyngeal infection with groups C and G
streptococci can cause acute
glomerulonephritis but has never been
shown to cause acute rheumatic fever

28
 Viruses

 Major cause of acute respiratory disease

 Influenza virus
 Parainfluenza viruses

 Rhinovirus

 Adenoviruses

 Respiratory syncicial virus

 Coronaviruses

29
symptoms of the common cold
The average adult gets 2 to 4 colds each year,

Presenting symptoms of the common cold may overlap

with those of GABHS pharyngitis, but the sore throat is
usually not severe, and odynophagia is unusual.
Patients usually complain of nasal symptoms
(rhinorrhea, nasal stuffiness) that lead the throat
symptoms. A nonproductive cough, hoarseness, and
low-grade fever may also be present.
The nasal mucosa is typically edematous, and the
oropharynx has mild erythema.
Specific virologic diagnosis is unnecessary for most
patients,because it usually does not affect the
management

30
 EBV

 EBV is the causative agent of infectious

mononucleosis (IM). The initial route of
infection occurs through the lymphoid
tissues and pharyngeal epithelial cells.

31
 CLINICAL COURSE
 The initial incubation period is from 3 to 7 weeks.
A prodrome of malaise, fever, and chills is
followed 1 to 2 weeks later by sore throat, fever,
anorexia, and lymphadenopathy (especially
cervical).
 Sore throat is found in 82% of patients with IM
and is the most common omplaint.
 Other symptoms may include abdominal
discomfort, headache, stiff neck, and skin rash

32
 EBV

 Diagnosis
 By Clinical presentation
 CBC with differential (atypical lymphocytes –T
lymphocytes)
 Detection of heterophil antibodies (Monospot test)

 IgM titers

33
 Diagnosis
 Infectious mononucleosis causes an absolute
lymphocytosis with more than 10% atypical
lymphocytes.
 Finding atypical lymphocytes on a peripheral
blood smear may be consistent with a clinical
impression of IM but is not specific for this
illness.
 Toxoplasmosis, cytomegalovirus, acute HIV-
infection, hepatitis A, tularemia, and rubella can
also be associated with this finding
34
 PHYSICAL EXAM
 Examination of the oropharynx reveals an
exudative pharyngitis with erythema and
tonsillar hypertrophy , diffuse lymphoid
hyperplasia of Waldeyer's ring, petechiae at the
hard palate-soft palate junction, and ulcers on
the pharyngeal and epiglottic mucosa

35
EBV petechiae

36
EBV

37
38
 Treatment
 Supportive management
 Rest
 Avoidance of contact sports (?->splenic rupture?)
 Steroids are indicated for complications related to
impending upper airway obstruction, severe hemolytic
anemia, severe thrombocytopenia, or persistent severe
disease

39
 Human Immunodeficiency Virus

 Acute human immunodeficiency virus (HIV) type 1

infection causes a mononucleosis-like syndrome in
40% to 90% of patients, which starts days to
weeks after exposure. This febrile illness is called
acute retroviral syndrome (ARS).
 Due to the nonspecific signs and symptoms, even
patients at risk for HIV are frequently not
promptly diagnosed.
 Thus ARS should be included in the differential
diagnosis in any patient with a fever of unknown
origin and risk factors for HIV exposure.
 symptoms and signs
 The most common symptoms and signs include
fever (median maximum temperature 38.9°C),
lethargy, skin rash, myalgia, headache,
 pharyngitis, cervical adenopathy, and arthralgia.
Pharyngitis occurs in 50% to 70% of patients
and usually appears as hypertrophy of the
tissues of Waldeyer's ring without exudates.
 Other oral manifestations that are less
commonly observed include ulcers (29%) and
candidiasis (17%).[88]
41
 Diagnosis
 Diagnosis is dependent upon laboratory tests.
 Complete blood count (CBC) may reveal
lymphopenia or trhrombocytopenia.6’
Atypical lymphocytes and a decreased CD4
cell count are usually not observed at this
time. Because antibodies to HIV appear
approximately 4 weeks later.
 A quantitative plasma HIV-1 RNA level,
tested by PCR, is necessary to make a timely
diagnosis
Arcanobacterium haemolyticum
 Arcanobacterium haemolyticum is a
nonmotile, β-hemolytic, gram positive
bacillus that causes 0.5% to 2.5% of
bacterial pharyngitis cases.24
 This organism also causes deep-seated
infections such as pneumonia, meningitis,
osteomyelitis, brain abscess, and
peritonsillar abscess

43
 A. haemolyticum
 Pharyngitis caused by A. haemolyticum is
easily mistaken for GABHS or viral
pharyngitis with an exanthem because of
the overlap in symptoms. When
suspected, throat culture needs to be
performed using 5% human blood agar.26
Using this culture media, prominent
hemolytic zones are formed within 24
hours by A. haemolyticum.
 Oral penicillin was recommended for
treatment in the past, but bactericidal tests demonstrated
increasing tolerance of this organism; thus first-line
antibiotic therapy for
 A. haemolyticumpharyngitis is erythromycin.
 Neisseria gonorrhoeae
Neisseria gonorrhoeae is a sexually transmitted
organism that affects the anogenital region but
can also cause gingivitis, stomatitis, glossitis,
and pharyngitis.
28.

Fellatio is the high risk behavior, and thus

the incidence of disease is highest in
homosexual males and females

46
 signs
Symptomatic patients usually come to medical attention
with findings suggestive of tonsillitis. The tonsils are
enlarged,and a white-yellow exudate arises from the
crypts.2
8 Oropharyngeal trauma may be evident, particularly on

the soft palate or uvula.

Fever (8%) and lymphadenopathy (9%) are uncommon
findings

47
 Treatment

 Recommended treatment is with a single

dose of intramuscular ceftriaxone.
 The higher dose of a 250-mg single
injection of ceftriaxone has improved
efficacy for pharyngeal infection.
 Corynebacterium diphtheriae
 Diphtheria is an example of an infectious
disease that has
 almost been eradicated by the application
of microbiologic and public health
principles and simultaneous
administration of diphtheria toxoid shortly
after World War II
 diphtheria

 Toxigenic strains are pathogenic,

 Toxin production is mediated by a
bacteriophage.
 The diphtheria exotoxin inhibits protein
synthesis in mammalian cells.
 Antitoxin neutralizes circulating toxin but is
ineffective once cell penetration has
occurred.
 diphtheria
 Transmission occurs through infected secretions from the
nose, throat, eyes, or skin lesions. Entry occurs through the
mouth or nose, and the organism initially remains localized to
the mucosal surfaces of the upper respiratory tract.

 Local inflammation and toxin-mediated tissue necrosis causes

formation of a fibrinous, patchy, adherent, gray-black
pseudomembrane.

 The location of pseudomembranes can be nasal, tonsillar,

pharyngeal, laryngeal, laryngotracheal, conjunctival, genital,
or cutaneous. More than one area can be affected, but the
oropharynx is the most commonly involved site
 diphtheria
 Toxin effects at distant sites cause myocarditis, neuritis, and acute
tubular necrosis. Myocarditis is associated with delayed
administration of antitoxin and typically occurs just as the local
disease is improving at 2 weeks after onset.
 Peripheral neuritis occurs 3 to 7 weeks later, usually affects motor
rather than sensory nerves, and commonly affects the soft palate
and pharyngeal muscles.
 Definitive diagnosis is based on isolation
of the organism.
 The pseudomembrane should be cultured,
 Treatment
 Treatment consists of both the antitoxin
and antibiotics.
 Outcome depends on the location and
extent of the pseudomembrane, the
patient’s immunization status, and how
quickly the antitoxin is administered. The
antitoxin should be given as soon as
possible, because it can only inactivate
toxin that has not already entered the
cells.
 booster injection
 . Diphtheria toxoid booster injection is
recommended every 10 years in adults.
 This is especially important for people who travel
to epidemic or endemic areas.
 Immunized patients can still be carriers for the
organism, because the vaccination is directed
solely against the toxin.
 When carriers are detected, treatment should
consist of a course of antibiotics and a toxoid
booster injection, if none was administered during
the previous year.
56
 oropharyngeal candidiasis
oropharyngeal candidiasis (OPC) is considered an
opportunistic infection and is now the most frequent opportunistic
infection found in symptomatic HIV-positive patients.93
In those who receive radiation for head and neck cancer,
Candida can be isolated in 73% of patients and can cause infection
in 27%.
94 Other populations at risk for disease include

those with xerostomia, either because of prior radiation to the

head and neck, from Sjögren syndrome, or as a side effect from
medications; people who use steroid inhalers or broad-spectrum
antibiotics; immunosuppressed individuals; people with diabetes
mellitus, Cushing syndrome, and terminally ill conditions;
and those on a high-carbohydrate diet.91

57
Initial therapy for uncomplicated OPC includes improving oral
hygiene and use of topical antifungals.91 Patients with a
refractory or recurrent infection and those at high risk for
systemic disease should be treated with systemic antifungals.

Fluconazole is the predominant medication used to treat OPC,

because the predominant organism, C. albicans, has
consistently shown sensitivity to the drug,

58
 Prophylaxis

Prophylaxis for patients at high risk for relapse of OPC has

been considered. Such populations include HIV-infected
patients, bone marrow transplant patients, patients with
chemotherapy-induced neutropenia, and those receiving radiation
for head and neck cancer. Fluconazole appears to be better
than nystatin in this regard.
91 OPC that responded to a 7-day course of fluconazole (200 mg/day).9

59
Thanks for your attention!