Differential diagnosis of pharyngitis

Main inflammatory throat diseases

PharyngitisTonsillitis, tonsillopharyngitisAdenoiditisParatonsillar abscessRetropharyngeal abscess

Classification of pharyngitisCatarrhal pharyngitis

- viral infections

Exudative pharyngitis - at viral infections (adenovirus, ЕВV) - purulent-exudative (GAS)

Membranous pharyngitis Diphtheria

Пpseudomembranous pharyngitis EBV infection Lysteriosis Syphilis Leukemia Burnt pharyngitis Oropharyngeal candidosis

Herpetic pharyngitis (НSV, enterovirus)

Non-infectious pharyngitis

SLE

Kawasaki Syndrome

Stivens-Johnson syndrome

Leukemia

Radiation damage

Burnt pharyngitis

Etiology of infectious pharyngitis

Bacteria (35-30 %)

Group A Streptococcus (65-80%)Group C and G Streptococcus (5-10 %)Arcanobacterium haemolyticum

Neisseria gonorrheaeCorynebacterium diphtheriaeMycoplasma pneumoniaeChlamydia pneumoniaeFrancisella tularensisCoxiella burnetii

Viruses (65-70 %)

Rhinovirus

Adenovirus

Epstein-Barr virus

Influenza

Parainfluenza

Enterovirus

Herpes simplex virus

Coronavirus

RS-virus

Clinics of viral pharyngitis

Catarrhal pharyngitis- Moderate sore throat, dryness- Moderate pharyngeal hyperemia- Follicular tonsillar hyperplasia- Serous exudate (+/-) at adenoviral and EBV

infections

Presence of other catarrhal signs: cough, rrhynitis, conjunctivitis

Moderate feverDisease course 3-7 days

Catarrhal pharyngitis

Pharyngitis at primary HIV infection

Incubation period is 3 to 5 weeks

Catarrhal pharyngitis sometimes with ulcers

Lymphadenopathy week before fever and pharyngitis

Other signs of HIV infection: arthralgias, myalgias, macule-papule rash, drowsiness

Pharyngitis at enteroviral infection

Common signs:Season – summer (“summer flu”)High feverMild pharyngeal hyperemiaNot typical:

- tonsillar exudate, - cervical lymphadenitis

Specific oropharyngeal signs : - herpangina – Сoxsackievirus A, B, Echovirus (papule-vesicles or nodules with hyperemia around on posterior

pharyngeal wall, 1-2 mm, with further ulcers and disappearance 5-7 days later)

- “hand-foot-mouth disease” - coxsackievirus A 16 (painful vesicles or ulcers in mouth cavity, on palms and soles;

fever subfebrile)

Herpangina at enteroviral infection

“Hand-foot-mouth disease” coxsackievirus A 16

Primary herpetic gingivostomatitis

Cause: HSV-1,2

In children under 5 years

High fever

Intense mouth pain (possible dehydration)

Ulcers in mouth: on lips, posterior pharynx, soft and hard palate

Disease course 1-2 weeks

Primary herpetic stomatitis

Oral candidosis

Oral candidosis

Streptococcus

Epidemiology of GAS Source: sick, carrier

Ways of transmission: Airborne, food-borne, watery

Season: Spring – Summer

Susceptible group: children of 5-15 years

Streptococcal (GAS) infection

Classification of GAS – associated diseases

1.  Purulent diseases: - respiratory infections; - skin and soft tissue infections; - systemic purulent infections. 2. Toxin – mediated infections (scarlet fever, TSS,

erysipelas). Infectious – allergic complications (rheumatic fever,

carditis, glomerulonephritis, PANDAS)

Streptococcal pharyngitis

Associated with hemolytic Streptococcus of groups А, С, G

Fever 39.5 С and higher, chills

Prominent throat pain and difficulty of swallowing

PE: “burning throat”, uvualr edema, Yellowish purulent covers in lacunas or tonsillar follicules

“Strawberry tongue” (papules + color)

Tense and painful tonsillar lymph nodes

Lacunar tonsillitis

Follicular tonsillitis

Streptococcal tongue

Laboratory diagnosis of streptococcal pharyngitis

Strep culture Reaction with bacitracin (inhibit growth of only GAS)Express tests: lattex agglutination, co-agglutination (Strep-test ) – determination of group polysaccharide antigenDetection of GAS DNA – (PCR, DNA-hybridization )Titer of anti-streptolysin O – 2-3 weeks later. Diagnostic titer - 1:300

GAS is the only widely spread etiology of pharyngitis which requires antibiotic therapy

Antibiotics at streptococcal pharyngitis

Penicillins (oral, parnetheral)

Cephalosporins of 1-2 generation

Macrolides

EВV infection

Infectious mononucleosis

Infectious mononucleosis is caused by Epstain-Barr virus and is characterized by:•Intoxication•Acute tonsillitis•Generalized polylymphadenopathy,•Hepatosplenomegaly

Diseases with mononucleosis-like syndrome

ЕВV infection – 90%

(infectious mononucleosis)

СМV infection

(cytomegaloviral mononucleosis)

HIV infection

Rubella

Toxoplasmosis

Viral hepatitis

Etiology of EBV

Family Herpesviridae – IV type

DNA-containing

Target cells - В- and Т- lymphocytes

Life-long persistense in B-cells

Oncogenic (Berkitt’s lymphoma, nasopharyngeal carcinoma, CNS lymphoma at HIV infection)

Epidemiology of EBV infectionWay of transmission:

contact (saliva), sexual, hemotransfusions

Children under 5 years – 80 %

In 50 % asymptomatic

After infection the person excretes the virus during 6 months; after – periodically through the life

Pathogenesis of EBV infectionPenetration and viral replication in pharyngeal mucosaViremia Infection of peripheral B-lymphocytesUncontrolled prolipheration of B-cells (CBC – absolute lymphocytosis and ESR)Responsive production of T-cells supressors (СД8+) for inhibition of B-cell proliferation (CBC – atypical mononuclears)Depression of cellular immunity

Clinics of EBV infection

Fever LymphadenopathyExudative pharyngitis (prominent)

Adenoiditis, nasal obstructionHepatomegalyPossible exanthema

Infectious mononucleosis

Pharyngitis at infectious mononucleosis

Pharyngitis at infectious mononucleosis

Pharyngitis at infectious mononucleosis

Complications of EBV infection

Respiratory tract obstruction (5-8%)Splenic rupture (0,5%)Neurologic disturbances:

- seizures, - Alice in Wonderland (metamorphopsia), - transverse myelitis, - facial paralysis, - meningitis (monocytic cytosis)

Hematological: - hemolytic and aplastic anemia, - thrombocytopenia, - neutropenia (2-3rd wk of the disease)

Laboratory diagnosis of EBV infection

Heterophylic test (antibodies) in children older 6 years (1:28 - 1:56)

Serologic – antibodies to early, capsid and nuclear antigens

CBC: leucocytosis (leucopenia), lymphocytosis,

atypical mononuclears, accelerated ESR.

Increased activity of ALT

Serological profile of EBV infection

Periods of the disease

At-EA

Early

AT-CA-IgM

Capsid

AT-CA-IgG

Capsid

AT-NA

Nuclear

Onset

(<1 week) + + + | - -Height

(1 - 4 weeks) + | - + + + | -

Recovery

(>4 weeks) _ _ + +

Therapy of EBV infection

NSAIDs (acetaminofen, ibuprofen) for feverCorticosteroids (on indications)Acyclovir – questionable.Marcolides – for exudative purulent pharyngitis. Azythromycin 10 mg/kg/day – 5 days

N.B.! Amoxicillin (ampicillin) is contraindicated

Indications for corticosteroid therapy

Airway obstruction

Autoimmune hemolytic anemia

Thrombocytopenia

Hemorrhagic syndrome

Seizures

Meningitis

25%-30% in childhood

Most common – GAS

Possible joining of anaerobic bacteria

Paratonsillar abscess

Symptoms

Throat pain / dysphagia 5-7 days No effect from antibiotics

Trismus Pain at mouth opening

Fever

Muffled voice

Pain irradiation into ear

Oropharyngeal signs

Assymetrical edema of soft tissue around tonsils with tonsillar dislocation

Fluctuation by palpation Tonsils can be normal, or hyperemic, or covered

with axudate Uvula is dislocated to healthy side Soft palate is hyperemic and edemstous Bilateral tonsillar involvement in 3% Malodor from mouth Cervical lymphadenopathy

Treatment

Penicillin G benzathine : Adults - 600 mg (~1 million U) IV q6h Children -12,500-25,000 U/kg IV q6h + Metronidazole (Flagyl) 15 mg/kg or 1 g per 70-kg adults IV during 1 hoursupportive dosage: 6 h infusion 7.5 mg/kg or 500 mg per 70-kg adults during 1 hour every 6-8h; not more than 4 g/d Clindamycin – infants and children : 15-25 mg/kg/d PO every 8h; 25-40 mg/kg/d IV/IM every 8h Erythromycin

Diphtheria

Acute anthroponous disease, caused by Gram(+) toxigenic bacillus Corynebacterium diphtheria, characterized by local fibrinous-inflammation of the mucus and/or skin, general intoxication and toxic complications: myocarditis, polyneuritis, nephrosis

Etiology of diphtheria1. Gram(+) aerobic bacillus. Non-

motile, non-encapsulated. Three variants: MITIS, GRAVIS and INTERMEDIUS.

2. All variants of toxigenic Corynebacterium produce identical toxin.

3. Non-toxigenic forms of Corynebacterium do not cause disease.

4. Corynebacterium is resistant to low and high temperatures and drying.

5. Situated in “X” or “V” pairs 6. Corynebacterium can be resistant

to erythromycin

Epidemiology of diphtheriaSeason – cold

Source – sicka and carriers

Transmission – airborne

70% population vaccination prevents epidemics

Pathogenesis of diphtheriaPenetration of bacillus

(no bacteriemia!)

Local fibrinous inflammation

Toxinemia and penetration of the toxin into tissues

Blocking of ribosomes and cell necrosis

Cardiomyocytes and conducting system

of the heart

Myelin layer of peripheral nerves

Tubular epithelium of the kidneys

Myocarditis Neuritis Nephritis

Classification of diphtheria

Diphtheria of tonsils

Diphtheria of nose

Diphtheria of larynx (croup, laryngitis)

Diphtheria of eye

Diphtheria of skin

Clinics of diphtheria

Incubational period = 2-10 days

Acute disease onset

Intoxication: moderate fever, headache, weakness

Fibrinous pharyngitis

Anterior cervical lymphadenitis

Subcutaneous cervical tissue edema

(+/-)

Membranous pharyngitisCyanotic hyperemia of pharynx

Tonsillar edema

Thick whitish-grayish covers, removed with bleeding of mucosa

Are formed by 3rd day of diphtheria

Pharyngeal diphtheria

Pharyngeal diphtheria

Tonsillar diphtheria

Tonsillar diphtheria

Symptoms of severe diphtheria

Toxic neck edema

Hemorrhagic syndrome

Shock (tachycardia, hypotension, oliguria)

Neck edema at diphtheria

Complications of diphtheria

Myocarditis

Neuropathies

Nephritis

Diagnosis of diphtheriaCulture of С.diphtheriae with detection of toxigenicity Detection of antibodies in reaction of neutralization (protective level is 0,5 U\ml)Detection of antibodies in reaction of direct hemagglutination (protective level is 1:320)Detection of phage (PCR)Detection of toxin in blood serumCBC: leucocytosis, neutrophilosis, accelerated ESRAt neuropathies – elevation of protein in CSF

Therapy of diphtheria

Antitoxin (serum): Minimal dosage: 20 - 40 thousand U Maximal dosage: 150 thousand U Route of injection: IM, IV

Antibiotics (erythromycin, penicillin - 14 days)

Prophylaxis of diphtheria

Vaccination with diphtheria anatoxin

- V1: 3, 4, (+\-) 5 months

- V2: 15 - 18 months

- V3: 4 - 6 years

- Later – every 10 years

Prophylaxis of contacts and carriers

Erythromycin or penicillin -7 days

Booster dose of anatoxin

Throat culture

Control throat culture 24 hours after antibiotic course