11 ‐ Pharyngitis Syndromes and Group a Strep Speaker: Karen C

11 ‐ Pharyngitis Syndromes and Group A Strep Speaker: Karen C. Bloch, MD, MPH, FIDSA, FACP

Disclosures of Financial Relationships with Relevant Commercial Interests

• None

Pharyngitis Syndromes Group A Strep

Karen C. Bloch, MD, MPH, FIDSA, FACP Associate Professor, Division of Infectious Diseases Vanderbilt University Medical Center *Special Thanks to Dr. Bennett Lorber!

Think Like A Realtor Think Like A Realtor Location Location Location

Pharyngitis Case 1 • Small square footage 38yo healthy female with 1 day of sore throat and fever. Childhood history of anaphylaxis to penicillin. • Micro-neighborhoods Physical exam T=102.3 • Regional differences HEENT-tonsillar purulence Neck-Tender bilateral anterior LAN Labs: Rapid antigen diagnostic test negative

Question 1 Group A streptococcus What is the most appropriate antimicrobial treatment? • AKA Streptococcus pyogenes A. Cephalexin • 5-15% sore throats in adults. B. None • Usually self-limited infection (even C. Doxycycline untreated) D. Clindamycin • Viral vs bacterial pharyngitis clinically E. Levofloxacin similar

Differentiating Pharyngitis Differentiating Pharyngitis

GAS Viral pharyngitis GAS Viral pharyngitis • Sudden onset • The 3 C’s • Fever – Conjunctivitis –Coryza • Onset in winter and early – Cough spring • Hoarseness • Lymphadenopathy • Diarrhea VS • Exposure to close contact • Ulcerative stomatitis with streptococcal • Tonsils red, but rarely pharyngitis enlarged or purulent

Modified Centor Score Streptococcal Clues

Points Strep probability Management 0 or 1 < 10% No antibiotic or culture • Palatal petechia • Scarletina 2 11 -17% Antibiotic if RADT or culture + 3 28 -35% Antibiotic if RADT or culture + 4 or 5 35-50% Antibiotic if RADT or culture +

• Centor criteria useful for negative predictive value to exclude streptococcal pharyngitis. • IDSA guidelines recommend antibiotics only following a positive testing.

Laboratory Diagnosis Strawberry tongue • Adults: • Group A strep – RADT screen, if negative, culture optional • Staph toxic shock • ASO titer or Anti-DNAse B antibodies – helpful in diagnosis of rheumatic fever and • Kawasaki disease post-streptococcal glomerulonephritis, but not for strep pharyngitis.

Treatment for GAS Pharyngitis Persistence vs Recurrence

• First line: PCN Allergic: • Asymptomatic carriers • Eradication regimens: – Oral Penicillin or – cephalosporin, (5% adults, >20% peds) – PCN or amoxicillin amoxicillin x 10 days clindamycin, • When to screen: monotherapy high rate of failure macrolides – Community outbreaks of strep (eg, dorm, barracks) – amoxicillin-clavulanate, – Not recommended: clindamycin or PCN plus – Family or personal h/o rifampin (4 days) tetracyclines, rheumatic fever sulfonamides, – To avoid tonsillectomy fluoroquinolones

Secondary Complications Pharyngitis and….

• Infectious complications • Immunologic complications

Pharyngitis & Rash Arcanobacterium haemolyticum • Young adult with fever, • Gram positive rod. sore throat, tonsillar exudate, scarlet fever-like • Scarletiniform rash in ~50%. rash • Treatment: azithromycin • Negative RADT and (clinda, PCN). culture. • Rarely life-threatening sequelae.

Pharyngitis & Rash Pharyngitis after Receptive Oral Intercourse • Acute HIV • Secondary syphilis Neisseria gonorrhoeae Herpes simplex virus • Highest risk MSM • HSV 1 or 2 • Most asymptomatic • Usually with acute • Nonspecific presentation infection • Diagnose by nucleic acid • Nonspecific presentation amplification test of • Oral or genital ulcers pharyngeal swab variably present

Pharyngitis & Conjunctivatis Pharyngitis and Vesicles

• College freshman with sore • 35 yo man with sore throat, low grade fever, and throat, fever, and conjunctivitis. lesions on palms & soles. His 3 yo son is sick • Roommate and 3 others in her with a similar illness. dorm with similar syndrome

• Caused by enteroviruses (most common Coxsackie virus) • Overlap with herpangina (oral lesions only) Epidemics in group living situations—barracks, dorms, camps, etc • More common in kids (often serve as vector)

Case 2 Case 2

• A 62 yo man presents with 24hr of fever, chills, odynophagia and diarrhea. • PE: T=102.4, HR=122, BP=97/52 • He works on a vineyard in Napa Valley, and last week Ill-appearing, left tonsil swollen and participated in the grape harvest. He admits to sampling erythematous the grape must. Left suppurative lymph node tender to palpation

WBC=12.3 CMAJ 2014;186:E62

Question 2 Oropharyngeal Tularemia

• Uncommon in the US What is the most likely cause of this patient’s illness? • Typically through ingestion (or rarely inhalation) – Inadequately cooked game A. Toxoplasmosis – Contaminated tap water (Turkey) B. Bartonellosis (Cat Scratch Fever) – Rodent contamination C. Tularemia • Exudative tonsillitis, ulcers, swollen LAN D. Epstein Barr virus • Diagnosis: culture (alert lab), serology E. Scrofula (mycobacterial lymphadenitis) • Treatment: streptomycin, doxycycline

Pharyngitis and Chest Pain Lemierre Syndrome

• 20 yo college student with sore throat, chills, GI upset. Despite oral amoxicillin, develops new onset of cough and pleuritic CP.

• Septic phlebitis of internal jugular vein • Often follows Streptococcal pharyngitis or mononucleosis • Classic cause is Fusobacterium necrophorum • Anaerobic gram-negative rod • Causes septic pulmonary emboli

Extra-Tonsillar Infections: 1 Extra-Tonsillar Infections: 2 • Epiglottitis • Vincent Angina – Fever, sore throat – AKA Trench mouth – Hoarseness, drooling, muffled voice, stridor – AKA acute necrotizing ulcerative – Examine with care! gingivitis – Lateral neck x-ray: Thumb sign – Oropharyngeal pain, bad breath – H. influenzae type B, pneumococcus – Sloughing of gingiva – Mixed anaerobes

Extra-Tonsillar Infections: 3 Case 3 • Ludwig Angina • A 42-year-old, previously healthy woman – Bilateral cellulitis of floor of the mouth – Often starts with infected molar is seen for a bad “sore throat” that began – Rapid spread with potential for airway 4 days earlier while attending her sister’s obstruction wedding in southern Ukraine. – Fevers, chills, drooling, dysphagia, muffled voice, woody induration of • She c/o malaise, odynophagia, and low neck – Mixed oral organisms (viridans strep, grade fever. Today, she noted a choking anaerobes) sensation, prompting medical evaluation.

Question 3 • T 100.2F; P 126; BP 118/74. HEENT: Submandibular swelling with gray exudate coating posterior pharynx. The most likely diagnosis is? An S3 gallop is heard. A. Streptococcal pharyngitis B. Kawasaki disease C. Vincent angina • CBC is normal. D. Diphtheria EKG shows: 1st degree AV nodal block, QT prolongation, and ST-T wave changes. E. Lemierre syndrome

Buzz words and Visual Associations Other clues Bull neck: • Location, location, location – Almost unheard of in developed countries (vaccination) – Large outbreak in former Soviet Union 1990s – Still an issue (high mortality) in developing world Grey pseudomembrane: extends onto palate or • Sore throat and myocarditis (~25%). uvula; bleeds when scraped • Sore throat and neuropathies (~5%). • Sore throat and cutaneous ulcer

Noninfectious Mimics • PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) • Still’s disease • Lymphoma • Kawasaki disease • Behçet disease’s

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Modified Centor Criteria

•C-”can’t” cough +1 •E-exudate +1 •N-neck adenopathy +1 •T-temperature elevation +1 •OR – Age less than 15 +1 – Age >44 -1