Re: Manjul Tripathi

Pharyngitis is one of the leading reason for physician visits by adults world wide. Approximately 10% of adults with pharyngitis who are seen by physicians are infected with group A Streptococcus (GAS)--the only etiology for which antibiotic treatment is currently acceptable. However, almost three-quarters of all patients with pharyngitis who present for medical care continue to receive antibiotics. In addition, doctors frequently prescribe broad-spectrum antibiotics, including the newer macrolides, although GAS remains sensitive to penicillin and is increasingly resistant to macrolides.

Guidelines from expert panels are shifting away from recommending positive culture results before antibiotic treatment and toward using clinical criteria and/or rapid testing for GAS (followed by confirmatory culture if the rapid test is negative). Neuner and colleagues (2003) conducted a cost-effectiveness analysis of five pharyngitis management strategies and studied the impact of a decision rule on those strategies. The five strategies chosen were observation only; empirical treatment with no testing; throat culture for all patients, with treatment for GAS-positive results; optical immunoassay (OIA) rapid testing, culture for negative results, and treatment for any positive result; and OIA alone, with treatment for positive results.

The baseline prevalence of GAS infection in pharyngitis was 9.7%. At this prevalence, the culture strategy was most effective and least expensive; it was followed in efficacy (in order) by OIA/culture, OIA alone, and observation. Empirical therapy was notably less effective than the other four strategies. The OIA/culture strategy was twice as expensive per patient as culture alone. For any prevalence between 6 and 20%, the culture strategy was most effective and least expensive. Only when OIA specificity was >98% did it become the more effective strategy, but culture remained least expensive at all specificity ranges. Only if the prevalence of GAS pharyngitis exceeded 71% would empirical treatment become the least expensive strategy. This point might be relevant if a highly predictive clinical decision rule was first applied to an individual patient.

This study supports the continued use of throat culture before the treatment of pharyngitis in adults as the most effective and least expensive approach. OIA with or without culture is more expensive but clinically effective. Empirical treatment at current prevalence rates of GAS pharyngitis is not recommended.

In an accompanying editorial, Bisno (2003) notes that the American College of Physicians has accepted the use of a clinical algorithm as a substitute for any microbiological testing in making decisions about the treatment of acute pharyngitis in adults. The American Academy of Family Physicians and the Centers for Disease Control and Prevention are supportive of this approach. In the study by Neuner's group, empirical treatment remained less effective and more expensive than other strategies, even when the best algorithm was used. Culture alone was most effective at the present U.S. prevalence of GAS pharyngitis. Because treatment has a minimal impact on clinical symptoms and contagion, and because suppurative or nonsuppurative sequelae are currently rare, the main goal in managing acute pharyngitis in adult patients should be to reduce the inappropriate use of antibiotics, particularly given the trend of physicians to prescribe broad-spectrum antibiotics. The Infectious Diseases Society of America now recommends the use of rapid antigen testing so that a decision regarding antibiotic treatment can be made quickly before the patient leaves the doctor's office. This approach is consistent with the study by Neuner and colleagues, which finds it to be as effective as culture alone, although more expensive. In any event, Bisno concludes that some testing should be performed; if treatment is indicated, penicillin is the drug of choice for nonallergic patients.

Having said the above, if treatment still fails, a re-evaluation of the the patient (in this case, your sister) should be done as the initial diagnosis maybe wrong. A step-wise approach should be taken and investigations retaken. Keep an open mind as to the diagnosis and keep looking out for differential diagnosis, as a once famous professor said - the eyes does not see what the mind does not know. :) Hope this helps and sorry for the extremely late reply. All the best in the recovery of your sister. God bless.

Sore throat (treatment)

- Most common (more than 90%) type of sore throat is viral pharyngitis. (virus causing inflammation to the throat/viral sore throat)

- How do you know if you’ve got a viral or bacterial sore throat?

o In bacterial sore throat, these are the signs & symptoms. (These suggest the presence of bacterial infection, and are not diagnostic in nature.)

§ Absence of cough

§ Tender cervical lymph nodes (painful lumps around the neck region upon pressing)

§ Enlarged tonsil with exudates

§ High grade fever ( more than 38⁰C )

o In viral sore throat, the symptoms are the direct opposite of the above, namely:

§ Presence of cough

§ Non-tender cervical lymph nodes

§ No enlarged tonsils

§ Low grade fever (<38⁰c)

- However, please note that with the presence of ALL 4 of the above signs and symptoms for bacterial sore throat, the chances of ACTUALLY having a bacterial sore throat is only about 50%(52.8%) according to research. (This is as good as tossing a coin to determine heads or tails. J) This percentage decreases with reduce in the number of signs and symptoms. Therefore, if you’ve only have 1 symptom among the 4 (mentioned above), the chances are slightly below 10% that you’ve got a bacterial infection.

- Other clues to help you determine if its viral or bacterial are: (This is not absolute)

o If you’ve been around people who cough or sneeze (at work or school) and subsequently (you and other healthy people exposed) get it within a matter of hours, it is most likely viral. (As viral sore throat is highly contagious, it spreads easily through contact of bodily fluids e.g. mucus or saliva) Bacterial sore throat usually takes hours to days to develop. Therefore, the best way to prevent sore throat is to avoid people who are sick, frequent effective hand washing technique and a healthy living.

o If you’ve been having it for more than a week (without the exposure to a constant source of new infected people), it is most likely bacterial. (A single episode of viral sore throat usually last for 3 to 7 days, but a bacterial last longer than a week. This is with the exception that you do not get repeated viral infections (e.g. being in a classroom full of students who are also coughing) as this might make it seem like a bacterial sore throat.)

- In light that most sore throat cases are viral infections rather than bacterial, what is the treatment for viral sore throat?

o Antivirals are effective in preventing and treating viral sore throats but are rather expensive and are not used for treatment of the ‘patty’ sore throat.

o If you can’t afford / get antivirals, there is only supportive therapy. (This means that you can only treat the symptoms individually i.e. bring down the fever by giving paracetamol (panadol) or relieve the pain by giving analgesics (pain-killer). However, this does NOT cure the root cause of the problem, but ONLY relieves the patient of his/her complaints! )

o The use of antibiotics is a clinically controversial issue.

o Theoretically, the use of antibiotics for viral sore throat is not encouraged. Reasons being:

§ There are no bacteria to kill, why use anti-bacteria? J (Please keep in mind that there are cases though no bacterial infection is detected, a high clinical suspicion for a potentially harmful bacterial infection is favoured and treated to prevent the unwanted side effects. Therefore, experience is needed for these.)

§ Widespread usage of antibiotics causes the emergence of anti-bacterial resistant bacteria. (most famous bacteria are MRSA / Methicillin-Resistant Staphylococcus Aureus & tuberculosis /TB bacteria – Mycobacterium tuberculosis)

§ Induction of bacterial infection. (The prolonged use of antibiotics will kill the local bacterial flora / “good bacteria” and this makes room for pathogenic bacteria / “bad bacteria” to colonise the free spaces that was made available for them.)

§ There are indications for antibiotic use in sore throats that are approved by WHO, but these are mainly for bacterial use.

o How about traditional medicine or home remedies?

§ Most of these methods are either passed down from generation to generation or from wise sayings / observations done by our ancestors. Though it might work for some, it is also true that it might not work for others. If it’s harmless, why not try it? J

§There are no scientific research done on most of these treatments, therefore no substantial proof can be used to backup the usage of these methods.

Karposi sarcoma (throat)

This is Karposi sarcoma (spot diagnosis-can't miss this)

Notice:

-a well elevated, round, purplish nodule just behind the right upper molar tooth.

-if you see this, think of retroviral infections (e.g. HIV)

-the dental fills are normally seen in most people

Streptococcal tonsillopharyngitis

This is a picture of Streptococcal tonsillopharyngitis:

Notice:

-severe inflammation involves both tonsils and pharynx with marked redness, swelling and exudate.

Follicular pharyngitis

This is Follicular pharyngitis due to Streptococcus pyogenes:

Notice:

-bilaterally enlarged and injected tonsils with pockets of yellowish exudates.

-non-injected palate (normal la...)

Ebstein-Barr Mononucleosis

This is a picture of Ebstein Barr Mononucleosis (EBM).

Notice:

-bilaterally enlarged tonsils but with whitish exudates.

-petechiae on soft palate. (tiny bleeds from vessels underneath the skin)

-lymph node enlargement (not seen in this picture but should be examined to help come to a diagnosis ^_^)

Quincy / Peritonsillar abscess

This is Quincy / Peritonsillar abscess.

Notice: (as the labels will show)

-the left tonsil is enlarged as compared to right.

-uvula is deviated to the right.

-a reddish area on the soft palate (abscess)

-this is seen in patient who usually have reccurent throat infections.

Orasl thrush

This is a typical picture of candida infection of the throat (or known as oral thrush).

Notice:

-small patches of whitish-yellow exudate on the palate, dorsum of tangue, pharynx and mucosa. (fungus growth)

-reddish patches surrounding the fungus growth.

-this is not common in a healthy individual, but often seen in patients with AIDS, severe uncontrolled diabetes mellitus.

Viral pharyngitis (pic)

This is a typical picture of viral pharyngitis.

Notice:

-slight post nasal drip (saliva + air blubbles behind the uvula)

-injected oropharynx (red throat wall)

-lymphoid enlargement (small swellings behing the throat wall)

Sore throat (physical examination)

•Inspection

–General appearance

–Nutritional status

–Hydration status

–Hoarseness of voice

•Hands

–Clubbing

–Nail changes

•Face

–Pallor

•Neck

–Thyroid enlargement ortendness

–Lymphadenopathy

•Inspection of oral cavity and pharynx

–Lips

–Angle of the mouth

–Halitosis

–Ulcers

–Abnormal masses

–Exudates

–Uvula

–Soft palate

–Tonsils

–Tongue

•Also inspect

–Ear for infections

–Ear pain

•Palpate

–Neck for cervical lymphadenopathy

–Sinus for tenderness

–Thyroid

Sore throat (All you should know about it)

Sore throat (How to take a history and do a physical examination)

Things to consider when having a sore throat: Sore throat diagnostic strategy model

Probability diagnosis • Viral pharyngitis • Chronic sinusitis with postnasal drip

Serious disorders not to be missed • Cardiovascular –Angina –MI • Neoplasia –Carcinoma of oropharynx, tongue –Blood dyscrasias (e.g. agranulocytosis, acute leukaemia-pharyngitis) • Severe infections –Acute epiglottitis (sudden onset in children) –Peritonsillar abscess –Pharyngeal abscess –Diphtheria –HIV / AIDS (candidiasis)

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Pitfalls (Often missed) • Foreign body (sore throat in the afternoon after meals) • Epstein Barr mononucleosis • Candida (fungal infection) • S.T.I.s (gonococcal, herpes simplex type 2) • Irritants (chronic sore throat – e.g. smoking, alcoholics, environmental irritant, postnasal drip, GERD) • Reflux esophagitis • Mouth breathing (e.g. morning sort throat due to nasal congestion-lack of humidification) • Thyroiditis Rarities (some are not, depends on the country u come from) • systemic sclerosis • sarcoidosis • malignant granuloma • tuberculosis

Seven masquerades checklist • Depression • Diabetes • Drugs • Anaemia • Thyroid disorder • Spinal dysfunction History taking: •Personal history •Determine the nature of sore throat –Sore throat –Deep pain in the throat –Neck pain •Character, onset, progression, severity, aggravating & relieving factors, seen a doctor(?). Associated symptoms –Fever –Chills & rigors –Headache –URTI –Difficulty swallowing –Ear pain –Nasal congestion / discharge –Cough –Tender cervical LN –Metallic taste in the mouth (candida) –Malaise –Bone pain (leukemaia) –GI symptoms (nausea, vomiting, abdo. Relevant Past Medical History: –Asthmatic on corticosteroid inhaler –CVS diseases –HIV / AIDS –DM –STIs –Reflux esophagitis –TB Family history: –Atophy –CVS diseases –Neoplasia Socail history: –Smoker & excessive alcohol beverage consumption –Living environment (environmental irritants, diseases) --History of travel