Thus, pharyngitis is a symptom, rather than a condition. Clinical management depends on the inciting cause of pharyngitis but ultimately can be separated into symptomatic and antimicrobial therapy. Microbial Causes of Acute Pharyngitis. To maximize accuracy, the tonsillar region and posterior pharyngeal wall should be swabbed. Maintaining adequate hydration is critical, regardless of treatment strategy. National Guideline Clearinghouse: Institute for Clinical Systems Improvement (ICSI). FOIA Neuner JM, Hamel MB, Phillips RS, et al. Diagnosis of the cause of pharyngitis is primarily achieved using key clinical features seen in the modified Centor or FeverPAIN scoring systems and, sparingly, with rapid antigen detection testing. government site. Streptococcus pyogenesgroup A streptococcus (GAS)infections (strep throat) occur in up to 30% and 15% of sore throats in pediatric and adult populations, respectively.2 Group A streptococcus infections can have life-threatening complications in less than 0.015% of pediatric and 0.05% of adult patients.4,5 These can be separated into nonsuppurative (acute rheumatic fever, glomerulonephritis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) and suppurative (peritonsillar abscess, septic jugular-vein thrombophlebitis, Vincent angina) complications that warrant urgent medical or surgical intervention.2,6. Voyez ", Sore throat and pharyngitis represent more than 2% and 5% of all outpatient primary care visits for adult and pediatric populations, respectively. Despite having a sensitivity of 70% to 92% and specificity of 96% to 100%,30 there is a 25% false-negative rate when used in the first 10 days of presentation.31 A sore throat caused by a virus resolves on its own. Dermatologic manifestations in concert with characteristic signs and symptoms serve as diagnostic criteria.13. Eighty percent of cases are caused by viral agents, while the remaining are bacterial and, rarely, fungal infections3 (Table 1). Physicians should also have a low threshold for suspecting suppurative complications, as they are life-threatening if untreated. Etiologic agents are passed through person-to-person contact, most likely via droplets of nasal secretions or saliva. All authors contributed to the interpretation of the literature and preparation of the manuscript for submission. Environmental and epidemiologic factors also may need to be assessed. In addition to the more common viral and bacterial causes of pharyngitis, a number of other causes of sore throat exist. Tonsillar hypertrophy, erythema, edema, or cobblestoning of the posterior pharynx suggest viral infections.2 Findings like upper-lip edema, splenomegaly, posterior cervical adenopathy, and polymorphic rashes increase suspicion for Epstein-Barr virus (EBV) infections.9,15 Bacterial pathogens might cause anterior cervical lymphadenopathy, sandpaperlike (scarlatiniform) rashes, tonsillar exudates, and palatal petechiae.16 Fungal pharyngitis presents with angular cheilitis and painful white curdlike plaques or smooth red patches within the oropharynx.14, Key physical findings in the oropharynx in viral, bacterial, and fungal pharyngitis, Patients can present with some or none of these signs and symptoms. Currently, there is no consensus on the length of restriction.44, Bacterial pharyngitis: Bacterial pharyngitis treatments focus on the eradication of GAS. Editorial commentary: antibiotics for treatment of acute respiratory tract infections: decreasing benefit, increasing risk, and the irrelevance of antimicrobial resistance. Antibiotic stewardship and the low incidence of streptococcal pharyngitis complications suggest that treatments can be largely supportive. When the clinical scenario suggests the presence of infectious mononucleosis, the diagnosis may be obtained by the presence of a positive heterophil antibody test (Monospot test) for Epstein-Barr virus. Etiologic agents are passed through person-to-person contact, most likely via droplets of nasal secretions or saliva. Before Attending Physician, Westside Health, Wilmington, DE. In most cases, the cause is an infection, either bacterial or viral. This information is necessary to support a diagnosis of rheumatic fever, but treatment for pharyngitis needs to begin before the return of serology laboratory results. She is hoping to obtain an antibiotic prescription to alleviate her symptoms. Randel A. AAO-HNS guidelines for tonsillectomy in children and adolescents. Bourbeau PB. sharing sensitive information, make sure youre on a federal Hence, negative results cannot rule out non-GAS bacterial pharyngitis. Federal government websites often end in .gov or .mil. When streptococcal pharyngitis is suspected, the physician should listen for the presence of a heart murmur and evaluate the patient for hepatosplenomegaly. This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. Sore throat is one of the most common reasons for visits to family physicians. Sore throat, odynophagia, and fever are all common features. Sore throat and pharyngitis represent more than 2% and 5% of all outpatient primary care visits for adult and pediatric populations, respectively.1 It is characterized by inflammation of the pharynx, nasopharynx, and tonsillar tissues.2 Incidence peaks between late winter and early spring. These should be immediately treated along with urgent or emergency otolaryngologist consultation. The pathophysiology of pharyngitis varies according to the etiology. Diagnosing strep throat in the adult patient: do clinical criteria really suffice? Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Tonsillopharyngitis is acute infection of the pharynx, palatine tonsils, or both. Thai TN, Dale AP, Ebell MH. Neoplastic processes can be more subtle, but may have accompanying weight loss, night sweats, fatigue, or dysphagia. A more recent article on streptococcal pharyngitis is available, Specimen obtained by throat swab of posterior tonsillopharyngeal area and inoculated onto 5 percent sheep-blood agar plate to which a bacitracin disk is applied; results in 24 to 48 hours, Sensitivity: 97 percent; specificity: 99 percent; results dependent on the technique, medium, and incubation, Rapid antigen detection test or rapid streptococcal antigen test, Detects presence of group A streptococcal carbohydrate on a throat swab (change in color indicates a positive result); results available within minutes; in-office test, Specificity: > 95 percent; sensitivity: 80 to 97 percent, depending on the test, Rapid slide agglutination test for mononucleosis, Overall sensitivity: 86 percent; overall specificity: 99 percent, First week sensitivity: 69 percent; specificity: 88 percent, Second week: sensitivity: 81 percent; specificity: 88 percent. In: Wang F, editor. Chlamydia pneumoniae or Mycoplasma pneumoniae can cause lower respiratory symptoms that are more severe, such as bronchitis, pneumonitis, or pneumonia, in addition to pharyngitis. Empirical antibiotic use should be limited to patients who are severely ill, have a high risk of complications, or show no signs of improvement within 5 days of presentation. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, Papola D, Lytvyn L, Vandvik PO, et al. Background. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Diagnosis and antibiotic treatment of group a streptococcal pharyngitis in children in a primary care setting: impact of point-of-care polymerase chain reaction. Anthony R, Flores MTC. ). Airway compromise, hoarseness, or neck swelling may accompany abscesses depending on their location. Differences among international pharyngitis guidelines: not just academic. (. Symptoms may include sore throat, odynophagia, cervical lymphadenopathy, and fever. Family physician in the Department of Family Medicine at Queens University in Kingston, Ont. Ressel G. Principles of Appropriate Antibiotic Use: Part I V. Acute Pharyngitis. Historical data from before 1975 also suggest that antibiotics reduce the risk of rheumatic fever by 67%, but newer studies exploring this complication are required.45 Concurrent antibiotic-corticosteroid therapy is not indicated, as it does not improve pain and might delay recovery from bacterial pharyngitis.46, Patients with a type 4 penicillin or amoxicillin hypersensitivity (rash) requiring antibiotics should receive 10 days of cephalexin, clindamycin, or clarithromycin.3 Similarly, patients with -lactamase type 1 hypersensitivity (anaphylaxis) can be prescribed a 5-day treatment of cefdinir or cefpodoxime.3 Cephalexin should be avoided in these patients, as there is a 2.5% risk of co-hypersensitivity to second-generation cephalosporins.47 Nonhypersensitivity maculopapular exanthems might appear in 70% of EBV-infected patients after amoxicillin, but do not require treatment.48 No statistical differences have been reported for symptom reduction between cephalosporin or macrolide treatments compared with penicillin.49, Atypical pharyngitis: Patients with infections refractory to first-line treatments can be treated for 72 hours with amoxicillinclavulanic acid or clindamycin. These point-of-care tests detect bacterial and viral antigens from throat swabs taken from tonsillar exudates or the posterior oropharynx using dipsticks. MIRIAM T. VINCENT, M.D., M.S., NADHIA CELESTIN, M.D., AND ANEELA N. HUSSAIN, M.D. Inclusion in an NLM database does not imply endorsement of, or agreement with, She denies having a cough or runny nose but has been febrile with intermittent chills. The most widely accepted of these tools is the Centor Clinical Prediction Rules for the diagnosis of GABHS in adults, which uses the presence (or absence) of four main criteria (see Table 2.1).4,12, Presence of 01 of the aboveno further testing indicated, Presence of 24 of the aboveGABHS testing indicated. Accessibility Laboratory testing serves as an adjunct to the history and physical examination (Table 1).1,2,4,6,7,11,17,2327, A systematic review of the clinical diagnosis of pharyngitis1 identified large, blinded, prospective studies using throat cultures as a reference standard. This article is eligible for Mainpro+ certified Self-Learning credits. Careers, Unable to load your collection due to an error. Trauma or throat strain caused by overuse (shouting, for example) should be elicited via the patient's history of symptom onset. First, the differential must be addressed through history and physical exam. Sore throat caused by pharyngitis is commonly seen in family medicine clinics and is caused by inflammation of the pharynx and surrounding tissues. Infectious causes range from generally benign viruses to GABHS. Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Common viral causes include the Epstein-Barr virus (mononucleosis), adenoviruses, enteroviruses, influenza A and B, and parainfluenza. Case fatality rates for noncutaneous diphtheria (5 to 10 percent) have remained constant for the past five decades.23 Diphtheria pharyngitis has recently (March 2001) been reported in Delaware County, Pa.24. Throat cultures have a reported sensitivity of 97 percent for GABHS and a specificity of 99 percent.24 It takes approximately 24 hours for the culture results to become available.13,23,26, Properly performed, a rapid antigen detection test is almost as sensitive as throat culture.17,26,27 Rapid streptococcal antigen tests are easy to perform, and results are available within minutes. Although a broad variety of differential diagnoses must be considered, ranging from infectious or inflammatory etiology to traumatic or neoplastic processes, the vast majority of these symptoms derive from either a viral or bacterial source. Pharyngitis caused by Streptococcus pyogenes is among the most concerning owing to its associated severe complications such as acute rheumatic fever and glomerulonephritis. The site is secure. 18 The optimal approach for differentiating among various causes of pharyngitis requires a problem-focused history, a physical examination, and appropriate laboratory testing.
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