Transcript Sore Throat (acute)

Mohammed El-Khateeb
MSVL-4
Nov 26th 2013
 The
respiratory system is the
most commonly infected system.
 Health
care providers will see
more respiratory infections than
any other type.
Geography of the respiratory system
(and sites of infection)
A major portal of entry for infectious organisms
 The upper respiratory tract:
 Mouth, nose, epiglottis, Nasal cavity, sinuses,
pharynx, and larynx
 Infections are fairly common.
 Usually nothing more than an irritation
 The lower respiratory tract:
 Lungs and bronchi
 Infections are more dangerous.
 Can be very difficult to treat
 The most accessible system in the body,
continuously exposed to potential pathogens.
 Breathing brings in clouds of potentially
infectious pathogens.
 The body has a variety of host defense
mechanisms.
 Innate immune response The cells and
mechanisms that defend the host from
infection by other organisms, in a nonspecific manner
 Adaptive immune It is adaptive immunity
because the body's immune system
prepares itself for future challenges.
Protective structures of the
respiratory system
 Ventilatory flow
 Involuntary responses such as coughing,
sneezing and swallowing
 Mucous membranes
 Hairs; ciliated epithelia
 Lymphoid tissues (tonsils)
 “Mucociliary escalator” keeps microbes
out of lower respiratory tract
 Alveolar macrophages; IgA
 Normal Flora:
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Moraxella,
nonhemolytic and a-strep,
Coryenbacterium,
Diphtheroids,
Candida albicans,
Others
Definition:
Inflammation of
the mucous
membranes and
submucosal
structures of the
oropharynx but
not tonsils
Sore Throate
30%-65%: idiopathic
30%-60%: viral
5%-10%: bacterial
Group A beta-hemolytic: most common
bacterial pathogen
 15%-36%: pediatric cases
 5%-10% : adult pharyngitis
 Disease of children
Strep.A
Mycoplasma
Strep.G
Strep.C
Corynebacterium
diphteriae
Toxoplasmosis
Gonorrhea
Tularemia
Rhinovirus
Coronavirus
Adenovirus
CMV
EBV
HSV
Enterovirus
HIV
Pharyngeal mucosa exhibits an
inflammatory response to many other
agents other than viruses
 Opportunistic bacteria
 Fungi
 Environmental pollutants
 Neoplasm
 Granulomatous disease
 Chemical and physical irritants
Sore throat is estimated to account for
10% of all general practice consultations
Asymptomatic carriage of streptococcus
 Is common with rates of 6 - 40%
 Carriers have low infectivity and are not
at risk of developing complications
such as rheumatic fever
Inflammation of the throat
Pain and swelling, reddened mucosa,
swollen tonsils, sometime white
packets of inflammatory products
Mucous membranes may swell,
affecting speech and swallowing
Often results in foul-smelling breath
Incubation period: 2-5 days
Sore throat
Pain on
swallowing
Fever
Hoarseness if
laryngeal
involvement
 Gradual onset
 Rhinorrhea
 Cough
 Diarrhea
Headache
Malaise
Redness of the pharynx and tonsils
Presence of exudate
Enlarged tonsils
Swollen tender neck glands.
Note that a streptococcal sore throat is
impossible to diagnose on clinical
grounds alone.
Full head and neck exam
 General – respiratory distress, toxic
 Face – mouth breathing
 Nose – rhinorrhea
 Neck – lymph nodes, thyroid,
 Mucosal edema, tonsillar swelling, exudates,
discrete lesions, deviation of the uvula or
tonsillar pillars, bulges in the posterior
pharyngeal wall
 Laryngoscopy
 Nasal endoscopy - sinusitis
 Treatment
VIRAL – Supportive care only – Analgesics,
Antipyretics, Fluids
No strong evidence supporting use of oral or
intramuscular corticosteroids for pain relief →
few studies show transient relief within first 12–24
hrs after administration
EBV – infectious mononucleosis
activity restrictions – mortality in these pts
most commonly associated with abdominal
trauma and splenic rupture
Commonly called a sinus infection
Most commonly caused by allergy
Can also be caused by infections or structural problems
Generally follows a bout with the common cold
Symptoms: nasal congestion, pressure above the nose
or in the forehead, feeling of headache or toothache
Facial swelling and tenderness common
Discharge appears opaque with a green or yellow color in
case of bacterial infection
Discharge caused by allergy is clear and may be
accompanied by itchy, watery eyes
 Also a common sequel of rhinitis
 Viral infections of the upper respiratory tract lead to
inflammation of the Eustachian tubes and buildup of fluid
in the middle ear- can lead to bacterial multiplication in
the fluids
 Bacteria can migrate along the eustachian tube from the
upper respiratory tract, multiply rapidly, leads to pu
production and continued fluid secretion (effusion)
 Chronic otitis media: when fluid remains in the middle
ear for indefinite periods of time (may be caused by
biofilm bacteria)
 Symptoms: sensation of fullness or pain in the ear, loss
of hearing
 Untreated or severe infections can lead to eardrum
rupture
Figure 21.2
 Most common agents in pharyngitis are the
rhinovirus and coronavirus
 Both single stranded, + sense RNA
picornaviruses
 Grow best at 33 degrees Celsius
 Approximates the temperature of the nasopharynx
 Disease is self-limited
 Clinical signs and symptoms may be
identical to bacterial pharyngitis
 Evaluation for Group A streptococcus is
advisable
Major cause of acute respiratory disease
 Rhinovirus &Coronaviruses
 Respiratory syncicial virus
 Parainfluenza viruses
 Respiratory syncicial virus
 Herpes Group
 HIV
 RHINOVIRUS INFECTION -There are several
hundred serotypes of rhinovirus.
 Fewer than half have been characterized.
 50% that have are all picornaviruses.
 Extremely small, non-enveloped, singlestranded RNA viruses
 Optimum temperature for picornavirus
growth is 33˚C.
 The temperature in the nasopharynx
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
PARAINFLUENZA: There are four types of
parainfluenza virus.
◦ All belong to the paramyxovirus group.
◦ Single-stranded enveloped RNA viruses
◦ Contain hemagglutinin and neuraminidase
Transmission and pathology similar to
influenza virus, but there are differences.
◦ Parainfluenza virus replicates in the
cytoplasm.
◦ Influenza virus replicates in the nucleus.
 Parainfluenza is genetically more stable
than influenza.
 Very little mutation
 Little antigenic drift
 No antigenic shift
 Parainfluenza is a serious problem in
infants and small children.
 Only a transitory immunity to reinfection
 Infection becomes milder as the child
ages.
Produces giant multinucleated cells (synctia)
in the respiratory tract
Most prevalent cause of respiratory infection
in the newborn age group
First symptoms: fever that lasts
approximately 3 days, rhinitis, pharyngitis,
and otitis
More serious infections give rise to symptoms
of croup: coughing, wheezing, dyspnea, rales
Etiologic agent of infectious mononucleosis
(IM)
 Herpes virus 4
 Double stranded DNA virus
 Selectively infects B-lymphocytes

Early infections in life are mostly
asymptomatic
 Clinical disease is seen in those with delayed
exposure (young adults)
 Defined by clinical triad
 Fever, lymphadenopathy, and pharyngitis
combined with +heterophil antibodies and
atypical lymphocytes

Other
clinical findings
Splenomegaly – 50%
Hepatomegaly – 10%
Rash – 5%
 Pharyngitis
White membrane covering one or
both tonsils
Petechial rash involving oral and
palatal mucosa

Diagnosis
 By Clinical presentation
 CBC with differential (atypical
lymphocytes –T lymphocytes)
 Detection of heterophil antibodies
(Monospot test)
 IgM titers
Supportive management
 Rest
 Avoidance of contact sports (?>splenic rupture?)
 Glucocorticoids (severe cases)

Complications
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Autoimmune hemolytic anemia
Cranial nerve palsies
Encephalitis
Hepatitis
Pericarditis
Airway obstruction
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
Herpes virus 5
Ubiquitous
50% of adults seropositive
10-15% of children seropositive by age 5
years
Etiology of 2/3 of heterophil-negative
mononucleosis
Clinical
manifestation
 Fever and malaise
 Pharyngitis and
lymphadenopathy less common
 Esophagitis in HIV infected
patients
Diagnosis
 4-fold rise in antibody
titers to CMV
Herpes (Greek word herpein, “to
creep”)
Two antigenic types (HSV-1, HSV2)
Both infect the upper
aerodigestive tract
Transmission is by direct contact
with mucous or saliva

Clinical manifestations
◦ Depends on
 Anatomic site
 Age
 Immune status of the host
◦ First episode (primary infection)
 More systemic signs and symptoms
 Both mucosal and extramucosal sites involved
 Longer duration of symptoms
Clinical manifestations:
• Gingivostomatitis and pharyngitis –
most common in first episode
• Usually in children and young adults
• Fever, malaise, myalgias, anorexia,
irritability

Physical exam
 Cervical lymphadenopathy
 Pharynx – exudative ulcerative lesions
 Grouped or single vesicles on an erythematous base
 Buccal mucosa
 Hard and soft palate

Clinical manifestations
•Acute illness evolves over 7-10
days
•Rapid regression of symptoms
•Resolution of lesions
Immunocompromised
patient


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Persistent ulcerative lesions are
common in patients with AIDS
Lesions more friable and painful
Aggressive treatment with IV
acyclovir
Diagnosis
Usually clinical
Isolation of HSV
Culture from scrapings of
lesions
oResults in 48 hours
Treatment
 Acyclovir, 400 mg PO 5X/day X 10days
 Valacyclovir, 1000 mg PO BID X 10 days
 Recurrent disease
 Acyclovir 400 mg PO 5X/day for 5
days
 Duration reduced from 12.5 to 8.1 days
 Acyclovir 400 mg po bid every day
 Recurrence reduced 36% to 19%

Pharyngitis
◦ Usually opportunistic infection
 HSV
 CMV
 Candida

Viral particles have been detected in
lymphoepithelial tissues of the pharynx