Differential diagnosis of pharyngitis Main inflammatory throat diseases

Differential diagnosis of pharyngitis

Main inflammatory throat diseases Pharyngitis Tonsillitis, tonsillopharyngitis Adenoiditis Paratonsillar abscess Retropharyngeal abscess

Classification of pharyngitis Catarrhal pharyngitis - viral infections Exudative pharyngitis - at viral infections (adenovirus, ЕВV) - purulent-exudative (GAS) Membranous pharyngitis Diphtheria Пpseudomembranous pharyngitis EBV infection Lysteriosis Syphilis Leukemia Burnt pharyngitis Oropharyngeal candidosis Herpetic pharyngitis (НSV, enterovirus)

Non-infectious pharyngitis SLE Kawasaki Syndrome Stivens-Johnson syndrome Leukemia Radiation damage Burnt pharyngitis

Etiology of infectious pharyngitis Bacteria (35-30 %) Group A Streptococcus (65-80%) Group C and G Streptococcus (5-10 %) Arcanobacterium haemolyticum Neisseria gonorrheae Corynebacterium diphtheriae Mycoplasma pneumoniae Chlamydia pneumoniae Francisella tularensis Coxiella burnetii Viruses (65-70 %) Rhinovirus Adenovirus Epstein-Barr virus Influenza Parainfluenza Enterovirus Herpes simplex virus Coronavirus RS-virus

Clinics of viral pharyngitis Catarrhal pharyngitis Moderate sore throat, dryness Moderate pharyngeal hyperemia - Follicular tonsillar hyperplasia - Serous exudate (+/-) at adenoviral and EBV infections Presence of other catarrhal signs: cough, rrhynitis, conjunctivitis Moderate fever Disease course 3-7 days

Catarrhal pharyngitis

Pharyngitis at primary HIV infection Incubation period is 3 to 5 weeks Catarrhal pharyngitis sometimes with ulcers Lymphadenopathy week before fever and pharyngitis Other signs of HIV infection: arthralgias, myalgias, macule-papule rash, drowsiness

Pharyngitis at enteroviral infection Common signs: Season – summer (“summer flu”) High fever Mild pharyngeal hyperemia Not typical: - tonsillar exudate, - cervical lymphadenitis Specific oropharyngeal signs : - herpangina – Сoxsackievirus A, B, Echovirus (papule-vesicles or nodules with hyperemia around on posterior pharyngeal wall, 1-2 mm, with further ulcers and disappearance 5-7 days later) - “hand-foot-mouth disease” - coxsackievirus A 16 (painful vesicles or ulcers in mouth cavity, on palms and soles; fever subfebrile)

Herpangina at enteroviral infection

“Hand-foot-mouth disease” coxsackievirus A 16

Primary herpetic gingivostomatitis Cause: HSV-1,2 In children under 5 years High fever Intense mouth pain (possible dehydration) Ulcers in mouth: on lips, posterior pharynx, soft and hard palate Disease course 1-2 weeks

Primary herpetic stomatitis

Oral candidosis

Oral candidosis

Streptococcus

Epidemiology of GAS Source: sick, carrier Ways of transmission: Airborne, food-borne, watery Season: Spring – Summer Susceptible group: children of 5-15 years

Streptococcal (GAS) infection Classification of GAS – associated diseases 1. Purulent diseases: - respiratory infections; - skin and soft tissue infections; - systemic purulent infections. 2. Toxin – mediated infections (scarlet fever, TSS, erysipelas). Infectious – allergic complications (rheumatic fever, carditis, glomerulonephritis, PANDAS)

Streptococcal pharyngitis Associated with hemolytic Streptococcus of groups А, С, G Fever 39.5 С and higher, chills Prominent throat pain and difficulty of swallowing PE: “burning throat”, uvualr edema, Yellowish purulent covers in lacunas or tonsillar follicules “Strawberry tongue” (papules + color) Tense and painful tonsillar lymph nodes

Lacunar tonsillitis

Follicular tonsillitis

Streptococcal tongue

Laboratory diagnosis of streptococcal pharyngitis Strep culture Reaction with bacitracin (inhibit growth of only GAS) Express tests: lattex agglutination, co-agglutination (Strep-test ) – determination of group polysaccharide antigen Detection of GAS DNA – (PCR, DNA-hybridization ) Titer of anti-streptolysin O – 2-3 weeks later. Diagnostic titer - 1:300

GAS is the only widely spread etiology of pharyngitis which requires antibiotic therapy

Antibiotics at streptococcal pharyngitis Penicillins (oral, parnetheral) Cephalosporins of 1-2 generation Macrolides

EВV infection Infectious mononucleosis

Infectious mononucleosis is caused by Epstain-Barr virus and is characterized by: Intoxication Acute tonsillitis Generalized polylymphadenopathy, Hepatosplenomegaly

Diseases with mononucleosis-like syndrome ЕВV infection – 90% (infectious mononucleosis) СМV infection (cytomegaloviral mononucleosis) HIV infection Rubella Toxoplasmosis Viral hepatitis

Etiology of EBV Family Herpesviridae – IV type DNA-containing Target cells - В- and Т- lymphocytes Life-long persistense in B-cells Oncogenic (Berkitt’s lymphoma, nasopharyngeal carcinoma, CNS lymphoma at HIV infection)

Epidemiology of EBV infection Way of transmission: contact (saliva), sexual, hemotransfusions Children under 5 years – 80 % In 50 % asymptomatic After infection the person excretes the virus during 6 months; after – periodically through the life

Pathogenesis of EBV infection Penetration and viral replication in pharyngeal mucosa Viremia Infection of peripheral B-lymphocytes Uncontrolled prolipheration of B-cells (CBC – absolute lymphocytosis and ESR) Responsive production of T-cells supressors (СД8+) for inhibition of B-cell proliferation (CBC – atypical mononuclears) Depression of cellular immunity

Clinics of EBV infection Fever Lymphadenopathy Exudative pharyngitis (prominent) Adenoiditis, nasal obstruction Hepatomegaly Possible exanthema

Infectious mononucleosis

Pharyngitis at infectious mononucleosis

Pharyngitis at infectious mononucleosis

Pharyngitis at infectious mononucleosis

Complications of EBV infection Respiratory tract obstruction (5-8%) Splenic rupture (0,5%) Neurologic disturbances: - seizures, - Alice in Wonderland (metamorphopsia), - transverse myelitis, - facial paralysis, - meningitis (monocytic cytosis) Hematological: - hemolytic and aplastic anemia, - thrombocytopenia, - neutropenia (2-3rd wk of the disease)

Laboratory diagnosis of EBV infection Heterophylic test (antibodies) in children older 6 years (1:28 - 1:56) Serologic – antibodies to early, capsid and nuclear antigens CBC: leucocytosis (leucopenia), lymphocytosis, atypical mononuclears, accelerated ESR. Increased activity of ALT

Serological profile of EBV infection

Therapy of EBV infection NSAIDs (acetaminofen, ibuprofen) for fever Corticosteroids (on indications) Acyclovir – questionable. Marcolides – for exudative purulent pharyngitis. Azythromycin 10 mg/kg/day – 5 days N.B.! Amoxicillin (ampicillin) is contraindicated

Indications for corticosteroid therapy Airway obstruction Autoimmune hemolytic anemia Thrombocytopenia Hemorrhagic syndrome Seizures Meningitis

25%-30% in childhood Most common – GAS Possible joining of anaerobic bacteria Paratonsillar abscess

Symptoms Throat pain / dysphagia 5-7 days No effect from antibiotics Trismus Pain at mouth opening Fever Muffled voice Pain irradiation into ear

Oropharyngeal signs Assymetrical edema of soft tissue around tonsils with tonsillar dislocation Fluctuation by palpation Tonsils can be normal, or hyperemic, or covered with axudate Uvula is dislocated to healthy side Soft palate is hyperemic and edemstous Bilateral tonsillar involvement in 3% Malodor from mouth Cervical lymphadenopathy

Treatment Penicillin G benzathine : Adults - 600 mg (~1 million U) IV q6h Children -12,500-25,000 U/kg IV q6h + Metronidazole (Flagyl) 15 mg/kg or 1 g per 70-kg adults IV during 1 hour supportive dosage: 6 h infusion 7.5 mg/kg or 500 mg per 70-kg adults during 1 hour every 6-8h; not more than 4 g/d Clindamycin – infants and children : 15-25 mg/kg/d PO every 8h; 25-40 mg/kg/d IV/IM every 8h Erythromycin

Diphtheria Acute anthroponous disease, caused by Gram(+) toxigenic bacillus Corynebacterium diphtheria, characterized by local fibrinous-inflammation of the mucus and/or skin, general intoxication and toxic complications: myocarditis, polyneuritis, nephrosis

Etiology of diphtheria Gram(+) aerobic bacillus. Non-motile, non-encapsulated. Three variants: MITIS, GRAVIS and INTERMEDIUS. All variants of toxigenic Corynebacterium produce identical toxin. Non-toxigenic forms of Corynebacterium do not cause disease. Corynebacterium is resistant to low and high temperatures and drying. Situated in “X” or “V” pairs Corynebacterium can be resistant to erythromycin

Epidemiology of diphtheria Season – cold Source – sicka and carriers Transmission – airborne 70% population vaccination prevents epidemics

Pathogenesis of diphtheria

Classification of diphtheria Diphtheria of tonsils Diphtheria of nose Diphtheria of larynx (croup, laryngitis) Diphtheria of eye Diphtheria of skin

Clinics of diphtheria Incubational period = 2-10 days Acute disease onset Intoxication: moderate fever, headache, weakness Fibrinous pharyngitis Anterior cervical lymphadenitis Subcutaneous cervical tissue edema (+/-)

Membranous pharyngitis Cyanotic hyperemia of pharynx Tonsillar edema Thick whitish-grayish covers, removed with bleeding of mucosa Are formed by 3rd day of diphtheria

Pharyngeal diphtheria

Pharyngeal diphtheria

Tonsillar diphtheria

Tonsillar diphtheria

Symptoms of severe diphtheria Toxic neck edema Hemorrhagic syndrome Shock (tachycardia, hypotension, oliguria)

Neck edema at diphtheria

Complications of diphtheria Myocarditis Neuropathies Nephritis

Diagnosis of diphtheria Culture of С.diphtheriae with detection of toxigenicity Detection of antibodies in reaction of neutralization (protective level is 0,5 U\ml) Detection of antibodies in reaction of direct hemagglutination (protective level is 1:320) Detection of phage (PCR) Detection of toxin in blood serum CBC: leucocytosis, neutrophilosis, accelerated ESR At neuropathies – elevation of protein in CSF

Therapy of diphtheria Antitoxin (serum): Minimal dosage: 20 - 40 thousand U Maximal dosage: 150 thousand U Route of injection: IM, IV Antibiotics (erythromycin, penicillin - 14 days)

Prophylaxis of diphtheria Vaccination with diphtheria anatoxin - V1: 3, 4, (+\-) 5 months - V2: 15 - 18 months - V3: 4 - 6 years - Later – every 10 years

Prophylaxis of contacts and carriers Erythromycin or penicillin -7 days Booster dose of anatoxin Throat culture Control throat culture 24 hours after antibiotic course