Emergency Department’s Case of the Month

A Pain in the Neck

Amanda Webb, BScH, and Katrina Hurley, MD, MHI, FRCPC

the common cold (rhinovirus and coron - Susan’s Case avirus) and other respiratory viruses (influen - Susan, a 14-year-old female, presents to the za virus, parainfluenza virus, and aden - pediatric ED with a 24-hour history of fever, left ovirus). 1 The second most common etiology upper quadrant pain, and vomiting. She reports feeling unwell for the past two weeks with upper is bacterial infection with group A respiratory tract infection (URTI)-like symptoms, sore ß-haemolytic (GABHS), throat, and decreased appetite. In triage she is found which© accounts for 15 to 30% of cases. 2 Non- o t n to be febrile (38.1 C), with a heart rate of ighGABHS bacteria can also causue pthairoyngitis 84 beats/min, respiratory rate of 20 breaths/min, yr rib op ist , blood pressure of 113/66, and oxyCgen saturation of in the pedlia trDic populationnl, obautd these organ - rcia n dow 100%. On exam she has marked pharyngeal e rs ca mm isemds, uinsceluding group lC u asned G Streptococci , inflammation, grey-white tonsillar exudat e,C ando horis rsona or d. Aut Arcan ofboarc tpereium h æmolyticum , Mycoplas- cervical lymphadenopatahy. lOen abdominal hexiabmit, eshe copy r S se pro single is tendte r ifn othe left uppeirs qeudad ruant and has a rint a ma pneumonia , and Chlamydia pneumoniae , No author and p palpable sUplenen 4 cm belowy ,t hvei ecowstal margin, with are far less common. Another etiology to displa appropriate bowel sounds, no other appreciable consider, particularly in adolescence, is masses, and no peritoneal signs. At a visit to her family doctor earlier in the week, a rapid strep test infectious mononucleosis, which is most was ordered for Susan and returned negative for commonly caused by the Epstein-Barr Group A Streptococcus (GAS). virus (EBV). 3

Read on for more on Susan. How do you investigate a patient 2. with a sore throat in the ED? Questions and Answers Although most cases of sore throat follow a benign course, assessment of the ABCs is What causes a sore throat in prudent. If, on general inspection, the patient 1. the pediatric population? has a toxic appearance and is sitting forward The most common cause of sore throat in with their head extended, epiglottitis should children is infectious . Infections be suspected. Immediate measures should be are usually self-limiting and are caused taken to protect the airway before further by both bacterial and viral pathogens. More examination is attempted. 4 Provided the serious bacterial causes of sore throat in- patient is stable, a focused history and physi - clude retropharyngeal abscess, peritonsillar cal examination are warranted. abscess, and epiglottitis, which can lead to Key elements in the history include symp - airway obstruction and respiratory compro - tom onset and progression, infectious con - mise if untreated (Table 1). tacts, presence of fever and/or fatigue, recent Most cases of infectious pharyngitis in travel, vaccinations, foreign body exposure, children are viral, including viruses that cause and sexual activity.

The Canadian Journal of Diagnosis / September 2012 1 Case of the Month

Table 1 Differential Diagnosis of Common Pediatric Causes of Pharyngitis 2–3, 5

Infection Common History Physical Diagnostic Age Tests Viral All ages • Rapid onset • Fever • Negative rapid • Systemic • Swollen pharynx strep test and symptoms • Cough • Headache • Rhinitis • Malaise • Conjunctivitis GABHS 5–15 years • Rapid onset • Fever/chills • Positive rapid • Seasonal • Palatal petechiae strep test and (fall, winter) • Pharyngeal exudate throat culture • Infection in • Lymphadenopathy family • Scarlatiniform rash • Anorexia • Vomiting Infectious Adolescents • Gradual onset • Fever • Negative rapid mononucleosis and adults • Fatigue and • White or grey-green strep test and malaise exudate throat culture • Posterior cervical • Positive lymphadenopathy monospot test • Hepatosplenomegaly

An examination of the oropharynx may infectious mononucleosis include the rapid reveal swelling and redness of the tonsils, test for streptococcal antigen (“rapid strep with or without exudate, and cervical lym - test”) and the heterophile antibody test phadenopathy in infectious pharyngitis. (“monospot”). In some institutions, a throat Bulging of the soft palate, deviation of the culture is still the test of choice. uvula, and trismus suggest a peritonsillar abscess. Limited movement of the neck, par - Table 2 ticularly in extension, is suspicious for 6 retropharyngeal abscess. Splenomegaly may McIsaac Strep Score be present if the patient has infectious Clinical Feature Points mononucleosis. Although no single or com - History of fever or 1 bined signs or symptoms can definitively temperature > 38.3 oC diagnose or exclude strep throat, the McIsaac Absence of cough 1 Strep Score is helpful. 5 A score of two or Tender anterior cervical 1 greater would warrant a rapid strep test or lymphadenopathy throat culture and a score of four or greater Tonsillar exudate 1 justifies use on clinical grounds Age < 15 years 1 alone (Table 2). 6 Further investigations that may help differ - Age ≥ 45 years -1 entiate between GABHS pharyngitis and

2 The Canadian Journal of Diagnosis / September 2012 Case of the Month

Retropharyngeal abscesses have been found to cause airway obstruction in up to 8% Back to Susan of cases and, if suspected, should be investi - Susan’s blood tests returned showing lymphocytosis gated further using a lateral soft tissue neck with 12% atypical lymphocytes. She was given acet - aminophen for pain control and was counseled on 6,7 radiograph or neck CT. A diagnosis of peri - appropriate management of her symptoms, including tonsillar abscess is usually made clinically, hydration and appropriate dosing of over the counter although CT, intraoral ultrasound, or aspira - pain relievers. She was advised to avoid contact tion may help differentiate between cellulitis sports for at least three weeks and to be assessed by her family doctor before return. Susan’s sore and abscess. throat resolved over the next two weeks, and she returned to her normal activities when her fatigue How can Susan be further improved about four weeks later. 3. investigated? Given Susan’s age, enlarged spleen, and other What are potential physical findings a clinical diagnosis of 4. complications of infectious infectious mononucleosis is made. Since no mononucleosis? specific therapeutic options are available to Most patients with infectious mononucleosis hasten recovery in patients with mononucle - have an uneventful recovery; however, com - osis, it is reasonable to make a diagnosis plications have been reported in a small per - based on the history and physical examina - centage of patients, including airway obstruc - tion alone. Options for further diagnostic test - tion, splenic rupture, and rash. 10, 11 Airway ing include a complete blood count, peripher - obstruction is rare but can arise from severe al blood smear, and a “monospot” test (Table pharyngeal and tonsillar inflammation. It is 3). Infectious mononucleosis may be accom - worse when supine and tends to occur about panied by lymphocytosis (> 50%) with atyp - one week after the onset of symptoms. 8, 11 ical lymphocytes (> 10%). 2 Liver enzymes Splenic rupture is a commonly feared com - have been reported to be mildly elevated in plication of infectious mononucleosis, yet it 90% of cases, specifically hepatic transami - has only been reported in 0.1 to 0.2% of nase levels during the second and third week patients. 10, 11 Pruritic morbilliform rashes of symptoms. 8,9 In the first week of the ill - have been reported to occur in up to 95% ness, the rate of false negatives for the het - of patients who are treated with amoxicillin erophile antibody test is 25%. 2 It is less use - or ampicillin. 2 The rash may last up to a ful in children under 14 years with a sensitiv - week and can affect the face, neck, trunk, ity of less than 50% in that age group. 9 extremities, palms, and soles. 2, 8, 11 To avoid

Table 3 Sensitivities and Specificities of Diagnostic Findings for Patients with Clinically Suspected Infectious Mononucleosis 2, 10

Investigation Sensitivity(%) Specificity(%) Lymphocytosis ( ≥ 50%) 66 84 Atypical Lymphocytes ( ≥ 10%) 75 92 Positive monospot test (< 50% 85 94 sensitive in children < 14 years)

4 The Canadian Journal of Diagnosis / September 2012 Case of the Month

this complication, it is safe to await throat patients should avoid contact sports and swab results prior to initiating for activities that cause increased abdominal suspected strep throat. pressure for at least three weeks from the onset of symptoms. 11 Before returning to What is the treatment? sports, patients should be assessed by their 5. family physician. Patients should be coun - The mainstay of treatment involves support - seled on how to avoid transmitting the infec - ive care and symptomatic relief. It is impor - tion to others, such as by avoiding close con - D tant to maintain fluid intake and adequate tact and not sharing beverages. x nutrition. Rest is also beneficial and symp - References toms can be managed with acetaminophen 1. Gerber MA: Diagnosis and Treatment of Pharyngitis in Children. Pediatr or nonsteriodal anti-inflammatory agents. Clin North Am 2005; 52(3):729–747, vi. 2. Luzuriaga K, Sullivan JL: Infectious Mononucleosis. N Engl J Med 2010; Corticosteroids and antivirals (acyclovir) are 362(21):1993–2000. not recommended for treatment of infectious 3. Ruppert SD: Differential Diagnosis of Common Causes of Pediatric Pharyngitis. Nurse Pract 1996; 21(4):38–42, 44, 47–48. 10,12 mononucleosis. Although corticosteroids 4. Jenkins IA, Saunders M: Infections of the Airway. Paediatr Anaesth. have been used to manage airway obstruc - 2009;19 (Suppl 1):118–130. 5. Shaikh N, Swaminathan N, Hooper EG: Accuracy and Precision of the tion, clinical benefit has only been reported Signs and Symptoms of Streptococcal Pharyngitis in Children: A for up to 12 hours, and their use remains Systematic Review. J Pediatr 2012; 160(3):487–493.e3. 6. McIsaac WJ, Goel V, To T, et al : The Validity of a Sore Throat Score in controversial due to associated adverse Family Practice. CMAJ 2000;163(7):811–815. 11,12 7. Marin J, Baren J: Pediatric Upper Airway Infectious Disease Emergencies. effects. There have been limited trials Pediatric Emergency Medicine Practice 2007;4(11):1–16. evaluating the use of antivirals in infectious 8. Bravender T: Epstein-barr Virus, Cytomegalovirus, and Infectious Mononucleosis. Adolesc Med State Art Rev 2010; 21(2):251–264, ix. mononucleosis. A meta-analysis of five ran - 9. Papesch M, Watkins R: Epstein-Barr Virus Infectious Mononucleosis. Clin domized controlled trials showed no consis - Otolaryngol Allied Sci 2001;26(1):3–8. 10. Ebell MH: Epstein-Barr Virus Infectious Mononucleosis. Am Fam tent symptomatic improvement with the use Physician 2004;70(7):1279–1287. of acyclovir in 339 patients. 13 Trials are 11. Putukian M, O’Connor FG, Stricker P, et al : Mononucleosis and Athletic Participation: An Evidence-based Subject Review. Clin J Sport Med underway to study an EBV vaccination, but 2008;18(4):309–315. they have yet to reach phase III. 14 12. Candy B, Hotopf M: Steroids for Symptom Control in Infectious Mononucleosis. Cochrane Database Syst Rev 2006; (3):CD004402. 13. Torre D, Tambini R: Acyclovir for Treatment of Infectious Mononucleosis: A Meta-analysis. Scand J Infect Dis 1999; 31(6):543–547. When is it safe to discharge a 14. Sokal EM, Hoppenbrouwers K, Vandermeulen C, et al : Recombinant 6. patient with infectious gp350 Vaccine for Infectious Mononucleosis: A Phase 2, Randomized, Double-blind, Placebo-controlled Trial to Evaluate the Safety, mononucleosis from hospital? Immunogenicity, and Efficacy of an Epstein-Barr Virus Vaccine in Healthy Worrisome symptoms that may call for extra Young Adults. J Infect Dis 2007;196(12):1749–1753. investigation or treatment include syncope, worsening abdominal pain, and inability to Ms. Amanda Webb is a Third Year Medical Student at manage secretions. Patients should be capa - Dalhousie University in Halifax, Nova Scotia. ble of taking oral liquids without difficulty, and should follow-up with their family physi - Dr. Katrina Hurley is an Assistant Professor in the cian or return to the ED if any of the above Department of Emergency Medicine and Medical Informatics Faculty, Dalhousie University, Halifax, Nova Scotia. symptoms develop. 7 Most cases of infectious mononucleosis resolve completely in a mat - Publication Mail Agreement No.: 40063348 ter of weeks; however, 9 to 22% of patients Return undeliverable Canadian addresses to: will experience fatigue for up to six months. 10 STA Communications Inc. 6500 Trans-Canada Highway, Suite 310 Due to the increased risk of splenic rupture, Pointe-Claire, QC, H9R 0A5

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