Current Issues in Pharyngitis:

Carlos A. Arango, M.D., F.A.A.P.

Assistant Professor

Department of Pediatrics

University of Florida

Pharyngitis

Inflammation of any structures of the

pharynx

Common cause of upper respiratory tract in

children

Diagnosed ~ 7 million times yearly

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

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

Clinical Features of GAS

Fever

Malaise

Headaches

Sore throat

Abdominal pain

Nausea

Vomiting

Physical Findings of GAS

Red pharynx

Petechiae in palate

Cervical adenopathy

Strawberry tongue

Scarlet Fever

Rash

– Erythrogenic exotoxin A

– Sand paper-like

– Circumoral pallor

– Pastia sign

– Desquamation

Diagnosis GAS

Rapid Antigen Tests

– Sensitivity ~ 75%

– Specificity ~95%

• Throat Culture

• Bacitracin disk

Diagnosis cont.

Serologic Evaluation

– ASO

– anti-DNase B

– Anti-Hyaluronidase

– ESR

– CRP

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

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

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

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.

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

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

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

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

Infectious Indications

for Tonsillectomy

Hyperplastic lymphoid tissue

Disproportionate amount of space occupied

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

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

PANDAS

Pediatric

Auto-immune

Neuropsychiatric

Disorder

Associated

Streptococcal infection

PANDAS

GAS triggers abrupt neuro-behavioral

symptoms

TICS/OCD

Auto-antibodies GAS cross react with

neuronal cells

Does PANDAS exist?

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

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)

Sydenham’s Chorea (SC)

and GAS

SC and GAS

Autoimmune process in RF with

antimyocardial antibodies

Anti-GAS Ab cross-react CNS neurons

This autoantibodies found healthy subjects

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

PANDAS and

Tourette Syndrome (TS)

Involuntary chronic motor/vocal tics

Tics exacerbates by stress, anxiety

Co-morbid neurobehavioral problem

– OCD, ADHD,anxiety

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)

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