PHARYNGITIS (TONSILLOPHARYNGITIS)

PRINCIPLES OF DISEASE
Pathophysiology
Inflammatory syndrom of the oropharnx primarily caused by infection
Transmission usually through respiratory secretions, but fomite, food
transmission also possible
Infection localizes in lymphatic tissue: tonsils, cervical ln.s
Rare significant complications of airway obstruction, decreased oral intake
and dehydration
Chronic pharyngitis: inflammation and infection of the tonsillar crypts
rather than the tonsils themselves
Beta-lactamase production is extremely common in bacteria responsible
for chronic pahryngitis
Microbiology
Viral most common cause: 80 - 90%; rhinovirus, adenovirus, coronavirus,
CMV, parainfluenza, rubella, influenza, HSV, coxsachie, EBV
Bacterial (children): group A Beta-hemolytic Streptococcus (GAS)
(Streptococcus pyogenes)
Bacterial (adults): Beta-hemolytic strep (all groups), H.flu, Mycoplasma,
Chlamydia
Other causes: Actinomyces, Francissella tularenssi, Yersinia
enterocolitica, Group B, C, G Streptococci
Cultures: often mixed aerobes (staph aureus, Hflu, moraxella) and
anaerobes (bactroides, anaerobic gram + cocci, fusobaclterium)
CLINICAL FEATURES
Hx:pharyngeal pain and odynophagia
PE: pharyngeal erythema, pharyngeal or tonsillar exudate, tonsillar enlargement,
tender
cervical lymphadenopathy
Strawberry tongue: petecheiae or hemorrhagic lesions suggesting scarlet fever
Gingival lesions with ulcerating tonsillitis and pseudomembranous exudate: Vincents
angina
Bull neck: diptheria
Vesicles: HSV, coxxachie
Rash: sand-papery with scarlet fever, erythematous maculopapular with EBV
Clinical differentiation of etiology is virtually impossible; some clues
Viral: associated rhinitis, cough, myalgia, headache, stomatitis,
conjunctivitis, exanhem, odynophagia, low-grade fever, white exudate;
cervical lymphadenopathy less common
Bacterial: rhinitis, conjuctivitis, exanthem, lymphadenopathy less common;
exudate, high fever, cervical lymphadenompathy, abscence of cough
more common
VIRAL PATHOGENS
Systemic viral infections: measles, CMV, rubella, HIV (mono-like illness)
Influenza: fever, headache, myalgias; 50% with pharyngeal pain but minority with
exudate and cervical lymphadenopathy
Adenovirus: 30% associated with conjunctivitis
Mononucleosis: pharyngitis is common presentation, tonsillar exudate or membrane
(creamy or cheesy whit), generalized lymphadenopathy in 90%, splenomegaly in 50%,
periorbital edema and rash less common. Macular rash after amoxicillin is common
(90% of those with mono given amoxil)

 HSV pharyngitis: young adults, painful superficial vesicles on erythematous base,

ulcers
may be present on lips/pharyng/tongue/gingiva/buccal mucosa, pharyngeal erythema
and exudate + fever + ln.s for 1-2 weeks, can be primary or secondary, bacterial
superinfection a complication
BACTERIAL PATHOGENS
Group A Beta-Hemolytic Streptococcus
primarily 5 - 15, winter and spring, incubation 12hr - 4 days
< 15% of pharyngitis in > 15yo, rare < 3 yo, epidemics occur
fever > 38.3, tonsillar exudates, palatal and uvular petechiae, uvular
edema and erythema, tender anterior cervical ln.s, absence of
cough/rhinitis.
Rash: associated with diffuse erythematous fine sandpaper rash, first in
flexor areas then generalized, concentrated in axilla, inguinal, popliteal
fossa; characteristically FADES on pressure; lasts 7 days then
desquamates (scarlet fever); not sensitive or specific; due to pyrogenic
toxin; occurs in minority
Pastias lines: petechiae in folds of the joints
Strawberry tongue can occur with scarlet fever
Toxic shock syndrome: sepsis and cardiovascular collapse, < 1%,
pyrogenic exotoxin A, high mortality
Diptheria
uncommon b/c of vaccinations, potentially lethal, consider in immigrants
sore throat, fever, dysphagia, gray or white exudate that coalesce to form
a pseudomembrane which is a gray-green layer over the tonsils,
pharyngeal mucosa, and occassionally the uvula and may extend to
involve the larynx (hoarseness, cough, stridor)
severe inflammation and edema can produce dysphonia and a bullneck
appearance
laryngeal, nasal, and cutaneous involvement possible (sharply
demarcated ulcer with membranous base)
must ask for special culture medium
Corynebacterium diptheriae produces a systemic toxin ----> myocarditis,
arrythmias, polyneuritis, vascular collapse, organ necrosis, death
Arcanobacterium hemolyticum
previously called Corynebacterium hemolyticum, 10 - 30 year old
similar to GAS pharyngitis, most have rash scarlatiniform/urticarial/or
erythema multiforme (may be only complaint)
usually nontoxic and afebrile; can produce membrane similar to diptheria;
associated with chronic pharyngitis
Vincents angina
anaerobic pharyngitis and acute necrotizing ulcerative gingivitis (ANUG)
also called Trench Mouth
etiology: Borellia vincenti
superficial ulceration and necrosis that often results in the formation of a
pseudomembrane and gingival lesions
food deposits in gingival crevice, gingivitis, frank ulceration and bleeding,
pseudomembranous necrotic exudate in gingival margins, spread to
tonsils and pharynx
foul-smelling breath, odynophadia, submandibular lymphadenopathy,
exudate often present, poor oral hygiene common
Gonococcal pharyngitis

 STD, may be independent of genital infection, can be asymptomatic

carrier, latent period common, important cause of gonococcemia
Syphillitic pharyngitis
primary or tertiary syphillus, painless mucosal lesions
Tuberculosis pharyngitis
hoarseness, dysphagia, pharyngeal ulcers in patient with advanced
disease
Candidal pharyngtitis
dysphagia, odynophagia, adherent white plaques with focal bleeding
points, immunocompromised
Mycoplasma pneumoniae
mild pharyngitis, epidemics occur, up to 10% of all adult pharyngitis, may
have LRTI as well
Chlamydia pneumoniae
epidemics, severe, selling and pain of deep cervical lymph nodes, +/LRTI, hallmarks are recurrence and persistence
Chlamydia trachomatis
STD, urogenital and partner testing required, mild symptoms or
asymptomatic
DIFFERENTIAL DIAGNOSIS
Deep space infections, Tumors, Foreign bodies
Pemphigus, Steven Johnson syndrome, Drug reaction
Allergic reaction, Angioedema
Chemical and thermal burns
Esophagitis, GERD
Epiglotitis, thyroiditis
DIAGNOSTIC STRATEGIES
Mononucleosis
Monospot: 95% sensitive in adults, 90% sensitive in > 5yo, 75% sensitive
in 2 - 4yo, 30% sensitive in 0 - 2yo; commonly negative in first week of
illness; specificity can be a concern as test may remain positive for up to
a year following the illness; POOR in young and early in dz
EBV IgM antibodies can be measured
EBV nuclear antigens develp w/i 3-6weeks and can be useful if initial
testing is negative
Peripheral blood smear reveals atypical mononuclear cells in 75% with
peak incidence in 2nd to 3rd week of illness
Group A Beta-Hemolytic Strep
Important to diagnose and treat w/ abx to prevent rheumatic fever
Antibiotic do NOT prevent post - strep glomerulonephritis
Difficult to dx or r/o accurately with clinical assessment
Serology: Anti-Streptolysin O (ASO) titers acute and convelescent are only
reliable way to diagnose; looks for grp A only; very specific but sensitivity
is variable (60 - 90%)
Throat swab cultures 90 - 95% sensitive for detection of Streptococcus
pyogenes but specificity (50%) may be poor as asymptomatic carriage is
common; lab only looks for GAS, must ask for diptheria etc
Rapid diagnostic tests: latex agglutination, ELISA, optical immunoassay,
chemiluminescent DNA probes; looks for streptococcal antigen in the
throat swab (only grp A); sensitivities range from 30 - 100% and
specificities range from 70 - 100% in trials but lower in practice; use is
controversial considering significant false +ve and false -ves

 Clinical scoring system

fever
> 38.3
cervical
lymphadenopathy
tonsillar
exudate
absence
of cough
Other testing
Diptheria: requires specific culturet, toxigenicity testing must also be
performed
A. hemolyticum: suspect if rash present, including EM
Vincents angina: clinical suspicion and a gram stain
Gonococcus: requires a Thayer-Martin agar
TB: requires acid-fast staining
Syphilus: dark-field microscopy, direct immunofluorescence, serology
Candida: yeast on KOH prep of throat swab or Sabourauds agar
Mycoplasma: serology or culture
Chlamydia: serology or antigen detection tests
HSV: culture of vesicles
MANAGEMENT
Group A Beta-hemolytic Strep
Clinical judgement unreliable, poor diagnostic tests, vastly overtreated
Benefit of antibiotics: shorten course of illness by < 1 day (2or3 vs 3or4),
decreases transmission, prevention of complications, decrease incidence
of rheumatic fever (or is a change in strain pattern, because rheumatic
fever rarely seen today compared to 50 years ago, is it really the antibiotic
use?)
Disadvantage of antibiotics: increased bacterial resistance, increased
recurrence, decreased immune response, patient expectation of abx
Rheumatic Fever: treatment w/i 9 days will prevent RF, incidence
dramatically decreased after antibiotic use, peak incidence in 5 - 15yo
where Grp A Beta - hemolytic strep common, currently occurs in 0.3% of
GAS pharyngitis and may increase to 3% with epidemics
Tonsillectomy: > 5 episodes per year
Antibiotics does NOT prevent post-strep glomerulonephritis
Four ED strategies
throat
culture all and only treat positives: costly, poor
specificity of positive culture b/c of carriage rate, delay in
waiting for cultures, problems with f/u from ED,
treat
all, culture all, stop if culture negative: ineffective and
costly
perform
rapid strep test and treat those who are positive:
false +ve lead to over treatment, negative test requires
follow up cultures,
treat
all who have reasonable clinical probabililty of GAS:
leads to over-treatment but avoids problems with testing

COMBINATION:
high clinical probability should be treated
without testing, low clinical probability should be treated if
testing is positive (culture or rapid strep testing)
Group A Beta-hemolytic Strep antibiotic regimen
Penicillin
V 250 mg po qid X 10days
Penicillin
V 250 mg po qid X 2/7 then 500 mg bid X 8/7
Benzathine
Penicillin 1.2 million units im X 1 dose
Frequent
dosing necessary, im dose has more reactions
Erythromycin
500 mg bid X 10/7 for pen allergic
Penicillin
failure due to noncompliance, re-infection, or Beta
- lactamase production; penicillin resistance growing,
erythromycin resistance uncommon
Alternatives:
cephalosporins, macrolads, clindamycin (not
shown to prevent RF although probably do)
Amoxicillin,
ampicillin, and penicillinase - resistant
penicillins offer no advantage over uncomplicated GAS
infections
Other Bugs
Diptheria: concern for toxicity and airway compromise; treat immediately if
suspecting, dont wait for tests; equine ANTITOXIN is indicated based on
clinical grounds, dose varies, consultation required; antibiotics eradicate
the bug but not the toxin, use erythromycin or rifampin; Td booster for
immunized contacts and erythromycin + full vaccination course for
unimmunized contacts
A. hemolyticum: erythromycin d of c b/c of penicillin resistance
Vincents angina: penicillin or clindamyucin and aoral oxidizing agent
(hydrogen peroxide)
Gonoccocus: ceftriazone 125 mg im or cipro/cifixime single dose;
concomitant treatment with azithromycin or doxy to cover chlamydia
TB: multiple drug regimen
Syphillus: benzthine penicillin 2.4 million units or doxycycline X 14 days
Candida: nystatin swish and swallow, versus oral

GAS CLINICAL SCORING SYSTEM

(i) fever > 38.3 (ii) cervical ln.s (iii) tonsillar
exudate (iv) NO cough
0 - 1: no treatment or testing
2 - 3 : test, treat if positive
4: treat empirically

fluconazole/itraconazole/clotirmazole; chronic suppression with HIV

Mycoplasma pneumonia: erythromycin, doxycycline, tetracycline
Chlamydial: doxy or macrolide
Recurrent tonsillitis: B-lactamase resistent antibiotics
HSV: acyclovir X 1 week if primary infection

 Steroids? Mayshorten the duration of symptoms without increasing the

complication rates
Symptomatic
Tylenol, ibuprofen
Warmed fluids, topical anesthetics (cepacol, etc)
Mononucleosis
Supportive, hydration, consider steroids
Avoid sports or contact for 6-8 weeks (risk of splenic rupture)
Acyclovir or famiciclovir if immunocompromized
DISPOSITION
Complications may necessitate consultation and admission: Airway compromise,
Local
and distant spread of infection, Deep neck abscesses, Necrotizing fascitis, Sleep apnea,
Bacteremia/sepsis
Complications of mono: airway obstruction, tonsillar and peritonsillar abscess, lingual
tonsillitis, necrotic epiglottitis, hepatic dysfunction, splenic rupture, neurologic disorders,
pneumonitis, pericarditis, hematologic disorders
GAS complications
Suppurative: PTA, RPA, deep space abcessess, suppurative cervical
lymphadenitis, OM, sinusitis, mastoidtits, bacteremia, sepsis, OM,
meningitis,
Nonsuppurative: RF, GN, pericarditis, myocarditis, erythema nodosum,
streptococcal toxic shock syndrome
Rheumatic
Fever: rare, 18 days after infection is average,
carditis and secondary valve disease, certain serotypes
more of a problem (with M-protein), prevented with abx w/i
9 days
Glomerulonephritis:
uncommon, 10 days after infection is
average, usually nephritic syndrome, uncommon
progression to CRF, serotype M-type 12, NOT prevented
by abx