current issues in pharyngitis
TRANSCRIPT
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Current Issues in Pharyngitis:
Carlos A. Arango, M.D., F.A.A.P.
Assistant Professor
Department of Pediatrics
University of Florida
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Pharyngitis
Inflammation of any structures of the
pharynx
Common cause of upper respiratory tract in
children
Diagnosed ~ 7 million times yearly
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Etiologic Agents
Viruses
Epstein-Barr Virus
Adenovirus
Enteroviruses
Herpes Simplex virus
Influenzae virus
Rhinoviruses
Coronavirus
RSV
Bacteria
Streptococcus (A,C,G)
Arcanobacterium hemolyticum
Corynebacteria diphteriae
Neisseria gonorrheae
Chlamydia pneumoniae
Mycoplasma pneumoniae
Yersinia enterocolitica
Francisellla tularensis
Coxiella burneii
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Group A Streptococcus (GAS)
Late winter-early spring
Transmission:
– Inhalation of large droplets
– Direct contact
Incubation period: 2-5 days
Abx eliminate contagiousness within 24 h
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Clinical Features of GAS
Fever
Malaise
Headaches
Sore throat
Abdominal pain
Nausea
Vomiting
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Physical Findings of GAS
Red pharynx
Petechiae in palate
Cervical adenopathy
Strawberry tongue
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Scarlet Fever
Rash
– Erythrogenic exotoxin A
– Sand paper-like
– Circumoral pallor
– Pastia sign
– Desquamation
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Diagnosis GAS
Rapid Antigen Tests
– Sensitivity ~ 75%
– Specificity ~95%
• Throat Culture
• Bacitracin disk
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Diagnosis cont.
Serologic Evaluation
– ASO
– anti-DNase B
– Anti-Hyaluronidase
– ESR
– CRP
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Treatment
Reduction of sequelae
– Suppurative
– Non-suppurative
Retropharyngeal abscess
Peritonsillar abscess
Cervical adenitis
Acute Otitis Media
Mastoiditis
Sinusitis
Bacteremia
Acute rheumatic fever
Acute phyelonephritis
Reactive arthritis
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How Bacteria Defend Against
-Lactam Antibiotics
Antibiotic
-Lactamase
Cytoplasm
Altered PBPs
Peptidoglycan cell wall
Plasma membrane
Chambers HF. In: Principles and Practice of Infectious Diseases. 2000:261-274.
Opal SM et al. In: Principles and Practice of Infectious Diseases. 2000:236-253.
-Lactam enzymes
inactivate -lactam
antibiotics
-Lactam antibiotics
do not bind as well
to altered PBPs
Reduced cell wall
permeability
inhibits antibiotic
entry
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Treatment
Penicillin (drug of choice)
– “Universally sensitive”
– Poor compliance
– Failure to eradicate GAS
from pharynx 15%
Amoxicillin
– Better taste
– Ease of use
Clinical / Bacteriologic
treatment failure Poor compliance
Tolerance of GAS to PNC
β-lactamase producing oral
flora
Lack of bacteriocins by
-streptococci , thus inhibiting
colonization of GAS
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How Bacteria Defend Against
Macrolides
Cytoplasm
Ribosomes
50
30
50
30
50
30
Bacteria alter macrolide binding site
(ermAM gene, MLSB phenotype)
Macrolide unable to block protein synthesis
Macrolide
Bacteria activate efflux pumps
(mefE gene, M phenotype)
Macrolide excreted from cell
Weisblum B. In: Gram-Positive Pathogens. 2000:694-710.
Hyde TB et al. JAMA. 2001;286:1857-1862.
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Treatment cont.
Macrolides
– Allergic to PNC
– Resistance pattern increasing
Spain 2002 GAS resistance
– 529 isolates=>417 TCx (78%)=>435 children
– 100% susceptible to PNC, Cefprozil
– 157 (30%) resistant to E/A, 1.3% C
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Treatment cont.
Cephalosporins
– Effective against group A streptococci
– Effective against -lactamase producing H. influenzae, M. catarrhalis and S. aureus
– Superior efficacy due to 2 phenomena:
Beta-lactamase producing bacteria
NO interference with alpha hemolytic streptococci
– Inhibits colonization of GAS
– Sensitive to PNC, relative resistance to cephalosporins
Excellent 2nd line of choice for treating GAS pharyngotonsillitis
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Chronic Pharyngeal Carriers
Persistent colonization 8.3% (+ TCx)
Confounding factors in diagnosis
When to treat?
– Sign and symptoms of pharyngitis
– Rapid test or culture positive
– Elevated streptococcal antibodies
– Use appropriate antibiotic
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cont
Reserve “special antibiotics”
– Anxious patient or family
– Hx of ARF
– Works in hospital, nursing homes
– “ping-pong’ spread among family members
Benzathine Penicillin + Rifampin
Clindamycin
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Infectious Indications
for Tonsillectomy
Hyperplastic lymphoid tissue
Disproportionate amount of space occupied
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Tonsillectomy cont
Upper Airway
Resistance Syndrome
– Mouth breathing
– Snoring
– Gasping
– Sleep pauses
– Restless sleep
– Enuresis
Obstructive Sleep
Apnea Syndrome
– > 20 sec pause
– 5-10 episodes/hour
– Cor pulmonale
– Polysommnography
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Indications for Tonsillectomy
cont Dysphagia
Speech impairment
Halitosis
Recurrent/chronic
pharyngotonsillitis
– 7 episodes/year
– 5 episodes/2 years
– 3 episodes/3 years
Peritonsillar abscess
Hemorrhagic tonsillitis
Tonsil asymmetry vs
Malignancy
– Adenopathy > 3cm
– Dysphagia
– Night sweats
– Fevers
PANDAS
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PANDAS
Pediatric
Auto-immune
Neuropsychiatric
Disorder
Associated
Streptococcal infection
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PANDAS
GAS triggers abrupt neuro-behavioral
symptoms
TICS/OCD
Auto-antibodies GAS cross react with
neuronal cells
Does PANDAS exist?
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Case 1
9 year old male with recurrent tonsillitis
3 documented GAS tonsillitis, 4 last year
TS (motor/vocal tics) for past year
Symptoms worsened with each episode of tonsillitis
ASO 170 U (nl <170)
T&A performed=>2 months later almost free of tics
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Case 2
Brother of 1st case
10 years old
Recurrent tonsillitis (5 documented/year)
OCD and anxiety disorder
T&A performed
3 weeks later playing outside (afraid of
leave home due to OCD)
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Sydenham’s Chorea (SC)
and GAS
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SC and GAS
Autoimmune process in RF with
antimyocardial antibodies
Anti-GAS Ab cross-react CNS neurons
This autoantibodies found healthy subjects
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PANDAS and
Sydenham’s chorea
Chorea involving face and extremities
Motor and vocal tics
Carditis (30-60%)
Elevated ASO (80%)
Clearly association with GAS
D8/17 Ab on surface of B lymphocyte
– Ayoub et-al
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PANDAS and
Tourette Syndrome (TS)
Involuntary chronic motor/vocal tics
Tics exacerbates by stress, anxiety
Co-morbid neurobehavioral problem
– OCD, ADHD,anxiety
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PANDAS and GAS
Swedo (1998) 50 children
– Premorbid personality
– Early age tics(6.3+2.3), OCD(7.4+2.7)years
– Relapsing-remitting pattern
– Dramatic/acute symptom exacerbation with relative
quiescent
– Association with GAS (72%)
– Tics BEFORE infection-related exacerbation should
EXCLUDE diagnosis PANDA (Sweto et al)
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DSM IV
Tics/OCD (preexisting tics should exclude diagnosis)
Prepuberal disorder
Sudden, explosive onset/worsening of tics
“positive ASO obtained at time of single exacerbation are not sufficient to prove that a child has PANDAS” Swedo et al.
Continue monitoring