SECTION 1 Respiratory Disorders 1 Sore Throat Robert R. Tanz Most causes of sore throat are nonbacterial and neither require nor are is rarely reason to test outpatients and infrequent benefit to testing inpa- alleviated by antibiotic therapy (Tables 1.1, 1.2, and 1.3). Accurate tients except to confirm and treat influenza. diagnosis is essential: Acute streptococcal pharyngitis warrants diag- Adenoviruses can cause upper and lower respiratory tract disease, nosis and therapy to ensure prevention of serious suppurative and ranging from ordinary colds to severe pneumonia and multisystem nonsuppurative complications. Life-threatening infectious complica- disease, including hepatitis, myocarditis, and myositis. The incubation tions of oropharyngeal infections, whether streptococcal or nonstrep- period of adenovirus infection is 2-4 days. Upper respiratory tract tococcal, may manifest with mouth pain, pharyngitis, parapharyngeal infection typically produces fever, erythema of the pharynx, and fol- space infectious extension, and/or airway obstruction (Tables 1.4 and licular hyperplasia of the tonsils, together with exudate. Enlargement 1.5). In many cases, the history and/or physical exam can help direct of the cervical lymph nodes occurs frequently. When conjunctivitis diagnosis and treatment, but the enormous number of potential causes occurs in association with adenoviral pharyngitis, the resulting syn- is too large to address all of them. drome is called pharyngoconjunctival fever. Pharyngitis may last as long as 7 days and does not respond to antibiotics. There are many adenovirus serotypes; adenovirus infections may therefore develop in VIRAL PHARYNGITIS children more than once. Laboratory studies may reveal a leukocytosis and an elevated erythrocyte sedimentation rate. Adenovirus outbreaks Most episodes of pharyngitis are caused by viruses (see Tables 1.2 and have been associated with swimming pools and contamination in 1.3). It is difficult to clinically distinguish between viral and bacterial health care workers. pharyngitis with a very high degree of precision, but certain clues may The enteroviruses (coxsackievirus and echovirus) can cause sore help the physician. Accompanying symptoms of conjunctivitis, rhini- throat, especially in the summer. High fever is common, and the throat tis, cough, discrete ulcerations, croup, or laryngitis are common with is erythematous but usually not bright red; tonsillar exudate and cervi- viral infection but rare in bacterial pharyngitis. cal adenopathy are unusual. Symptoms resolve within a few days. Many viral agents can produce pharyngitis (see Tables 1.2 and 1.3). Enteroviruses can also cause meningitis, myocarditis, rash, and two Some cause distinct clinical syndromes that are readily diagnosed specific syndromes that involve the oropharynx. without laboratory testing (Table 1.6; see also Tables 1.1 and 1.4). In Herpangina is characterized by distinctive discrete, painful, gray- pharyngitis caused by parainfluenza and influenza viruses, rhinovi- white papulovesicular lesions distributed over the posterior orophar- ruses, coronaviruses, and respiratory syncytial virus (RSV), the symp- ynx (see Table 1.6). The vesicles are 1-2 mm in diameter and are toms of coryza and cough often overshadow sore throat, which is initially surrounded by a halo of erythema before they ulcerate. Fever generally mild. Influenza virus may cause high fever, cough, headache, may reach 39.5°C. The illness is due to enteroviruses and generally lasts malaise, myalgia, and cervical adenopathy in addition to pharyngitis. less than 7 days, but severe pain may impair fluid intake and occasion- In young children, croup or bronchiolitis may develop. When influenza ally necessitates medical support. is suspected on clinical and epidemiologic grounds or confirmed by Hand-foot-mouth disease is caused by coxsackievirus A16. Painful testing (polymerase chain reaction [PCR] is most accurate), specific vesicles that ulcerate can occur throughout the oropharynx. Vesicles antiviral therapy is available for treatment of patients and prophylaxis also develop on the palms, soles, and, less often, on the trunk or of family members. RSV is associated with bronchiolitis, pneumonia, extremities. Fever is present in most cases, but many children do not and croup in young children. RSV infection in older children is usually appear seriously ill. This disease lasts less than 7 days. indistinguishable from a simple upper respiratory tract infection. Primary infection caused by herpes simplex virus (HSV) usually Pharyngitis is not a prominent finding of RSV infection in any age produces high fever with acute gingivostomatitis, involving vesicles group. Parainfluenza viruses are associated with croup and bronchiol- (which become ulcers) throughout the anterior portion of the mouth, itis; minor sore throat and signs of pharyngitis are common at the including the lips. There is sparing of the posterior pharynx in herpes outset but rapidly resolve. Infections caused by parainfluenza, influ- gingivostomatitis; the infection usually occurs in young children. enza, and RSV are often seen in seasonal (winter) epidemics. Many High fever is common, pain is intense, and intake of oral fluids is agents can be identified using multiplex or targeted PCR testing, but there often impaired, which may lead to dehydration. In addition, HSV may 1 CHAPTER 1 Sore Throat 1.e1 (See Nelson Textbook of Pediatrics, p. 2019) 2 SECTION 1 Respiratory Disorders TABLE 1.1 Etiology of Sore Throat TABLE 1.2 Infectious Etiology Infection of Pharyngitis Bacterial (see Tables 1.2, 1.3) Definite Causes Viral (see Tables 1.2, 1.3) Streptococcus pyogenes (Group A streptococci) Fungal (see Table 1.3) Corynebacterium diphtheriae Neutropenic mucositis (invasive anaerobic mouth flora) Arcanobacterium haemolyticum Tonsillitis Neisseria gonorrhoeae Epiglottitis Epstein-Barr virus Uvulitis Parainfluenza viruses (types 1–4) Peritonsillar abscess (quinsy) Influenza viruses Retropharyngeal abscess (prevertebral space) Rhinoviruses Ludwig angina (submandibular space) Coronavirus Lateral pharyngeal space cellulitis-abscess Adenovirus (types 3, 4, 7, 14, 21, others) Buccal space cellulitis Respiratory syncytial virus Suppurative thyroiditis Herpes simplex virus (types 1, 2) Lemierre syndrome (septic jugular thrombophlebitis) Vincent angina (mixed anaerobic bacteria–gingivitis–pharyngitis) Probable or Occasional Causes Group C streptococci Irritation Group G streptococci Cigarette smoking Chlamydia pneumoniae Inhaled irritants Chlamydia trachomatis Reflux esophagitis Mycoplasma pneumoniae Chemical toxins (caustic agents) Paraquat ingestion Smog Dry hot air Hot foods, liquids TABLE 1.3 Additional Potential Pathogens Other Associated with Sore Throat Tumor, including Kaposi sarcoma, leukemia Bacteria Granulomatosis with polyangiitis (formerly Wegener granulomatosis) Fusobacterium necrophorum (Lemierre syndrome) Sarcoidosis Neisseria meningitidis Glossopharyngeal neuralgia Yersinia enterocolitica Foreign body Tularemia (oropharyngeal) Stylohyoid syndrome Yersinia pestis Behçet disease Bacillus anthracis Kawasaki syndrome Chlamydia psittaci Posterior pharyngeal trauma—pseudodiverticulum Secondary syphilis Pneumomediastinum with air dissection Mycobacterium tuberculosis Hematoma Lyme disease Systemic lupus erythematosus Corynebacterium ulcerans Bullous pemphigoid Leptospira species Syndrome of periodic fever, aphthous stomatitis, pharyngitis, cervical Mycoplasma hominis adenitis (PFAPA) Virus Coxsackievirus A, B manifest as pharyngitis in adolescents. Approximately 35% of new- Cytomegalovirus onset HSV-positive adolescent patients have herpetic lesions; most Viral hemorrhagic fevers teenage patients with HSV pharyngitis cannot be distinguished from Human immunodeficiency virus (HIV) (primary infection) patients with other causes of pharyngitis. The classic syndrome of Human herpesvirus 6 herpetic gingivostomatitis in infants and toddlers lasts up to 2 weeks; Measles data on the course of more benign HSV pharyngitis are lacking. The Varicella differential diagnosis of vesicular-ulcerating oral lesions is noted in Rubella Table 1.6. Fungus A common cause of a local and large lesion of unknown etiology Candida species is aphthous stomatitis (Fig. 1.1). PFAPA (periodic fever, aphthous Histoplasmosis stomatitis, pharyngitis, and cervical adenitis) is an idiopathic periodic Cryptococcosis fever syndrome that occurs predictably every 2-8 weeks. The onset of PFAPA is usually before the age of 5 years. In addition to aphthous stomatitis and pharyngitis, PFAPA is characterized by high fever lasting 4-6 days. Individual episodes resolve spontaneously but may respond TABLE 1.4 Distinguishing Features of Parapharyngeal–Upper Respiratory Tract Infections Postanginal Submandibular Lateral Laryngotracheo- Sepsis Peritonsillar Retropharyngeal Space (Ludwig Pharyngeal Masticator bronchitis Bacterial (Lemierre Abscess Abscess (Cellulitis) Angina)* Space Space* Epiglottitis (Croup) Tracheitis Syndrome) Etiology Group A Staphylococcis aureus, Oral anaerobes† Oral Oral Haemophilus Parainfluenza virus; Moraxella Fusobacterium streptococci, oral anaerobes,† group anaerobes† anaerobes† influenzae type influenza, adenovirus, catarrhalis, necrophorum oral anaerobes† A streptococci, b (rarely), group and respiratory S. aureus, “suppurative adenitis” A streptococci, syncytial virus less H. influenzae Streptococcus common type b or pneumoniae, nontypable Staphyloccocus aureus, and non-type b H. influenzae Age Teens