Doctor, I Have Strep Throat Nancy W Weber D.O. FACOEP FACEP MBA Sparrow/MSU Emergency Medicine Residency October 22, 2018
Disclosures None
The Patient: 41YOF CC: Sore throat x 3 days HPI: Sore throat increasing x 3 days, not relieved with OTC meds Odynophagia, Dysphagia decreased p.o. intake Fever x 3 days, maximum 102.0F, chills Differential Diagnosis?
DDx: Sore Throat and Fever Common Causes: Viral pharyngitis Including Mononucleosis, Coxsackie, etc. Bacterial pharyngitis Including Strep, Rheumatic fever, Peri-tonsillar abscess Dental Infection What ROS can help expand our DDx?
Negative ROS: Denies URI/LRI/CV: no earache, otalgia, rhinorrhea, congestion, changes in vision or hearing, no CP, syncope, palpitations, SOB, wheeze or cough Denies GI, GU: no nausea, vomiting, diarrhea, abdominal pain, change in bowel habits, no dysuria, hematuria, flank pain No neurologic, MSK, skin complaints: no numbness, tingling, syncope, weakness, no change in ROM, myalgias, arthralgias, muscle tenderness, no lesions, non-healing wounds, ulcers But this is a CPC presentation, right???
Infectious Additional DDx: Epiglottitis Odynophagia, Dysphagia Less Common Causes: Diphtheria Bacterial Tracheitis Fusobacterium Necrophorum (Lemiere s disease) Retropharyngeal abscess STD s including: Gonorrhea, Chlamydia, Syphilis, Herpes AIDS pharyngitis, Candida esophagitis, IRIS HAV, HBV, HCV Travel related infections Country of origin, Recent travel Meth mouth Ingestion: Foreign body caustic vs alkali burns, thermal burns Drug Reaction including SJS/TENS Fixed Drug Reaction Stud infection/chemical reaction from stud Cancer: Leukemia, Lymphoma, Pharyngeal carcinoma, squamous cell carcinoma Compression: Internal/External/Mural Autoimmune: serositis, myositis Sweet s Syndrome Congenital disorders, including brachial cyst So what more can our patient tell us?
HPI, continued + Smoker Denies IVDA, no EtOH, no illicits Denies risky sexual behavior No current medications, including no immuno-suppressants What else could this be?
Everybody Lies! Thanks, Dr. John Dery youtube.com, Everybody Lies/House M.D. Season 1, episode 21
But What s Missing from our HPI? Travel Country of Origin Sick Contacts Family History More detailed Psychiatric History Any weight loss before 3 days of Sore Throat and Fever? History of Bipolar, Epilepsy, HTN and no meds??? What does Denies Risky Sexual Behavior mean to patient? To provider?
PMHx: Bipolar I, Depression Epilepsy GERD Smoker No PCP HTN Reliability of HPI Adverse Drug Reaction Esophagitis, Barrett s, Carcinoma Squamous Cell Carcinoma of lips, tongue, oral cavity, pharynx, larynx, esophagus No regular screening/check-ups (no interactions) So back to our Differential Diagnosis
Infectious Epiglottitis Additional DDx: Odynophagia, Dysphagia Less Common Causes: Diphtheria Bacterial Tracheitis Fusobacterium Necrophorum (Lemiere s disease) Retropharyngeal abscess STD s including: Gonorrhea, Chlamydia, Syphilis, Herpes AIDS pharyngitis, Candida esophagitis, IRIS HAV, HBV, HCV Travel related infections Country of origin, Recent travel Meth mouth Ingestion: Foreign body caustic vs alkali burns, thermal burns Drug Reaction including SJS/TENS Fixed Drug Reaction Stud infection/chemical reaction from stud Cancer: Leukemia, Lymphoma, Pharyngeal carcinoma, squamous cell carcinoma Compression: Internal/External/Mural Autoimmune: serositis, myositis Sweet s Syndrome And the final diagnosis Congenital disorders, including brachial cyst
Final Diagnosis: AIDS defining pharyngitis
AIDS Defining Illness Candidiasis of bronchi, trachea, or lungs Bacterial infections, multiple or recurrent* Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonary Herpes simplex: chronic ulcers (>1 month's duration), bronchitis, pneumonitis, or esophagitis Histoplasmosis, disseminated or extrapulmonary Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary Mycobacterium tuberculosis of any site, pulmonary, disseminated, or extrapulmonary Mycobacterium, other species or unidentified species, disseminated or extrapulmonary Cervical cancer, invasive Cryptosporidiosis, chronic intestinal (>1 month's duration) Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month Cytomegalovirus retinitis (with loss of vision) Encephalopathy, HIV related Isosporiasis, chronic intestinal (>1 month's duration) Kaposi sarcoma Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex* Lymphoma, Burkitt (or equivalent term) Lymphoma, immunoblastic (or equivalent term) Lymphoma, primary, of brain Pneumocystis jirovecii pneumonia Pneumonia, recurrent Progressive multifocal leukoencephalopathy Salmonella septicemia, recurrent Toxoplasmosis of brain, onset at age >1 month Wasting syndrome attributed to HIV https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a2.htm
References/Credits: youtube.com, Everybody Lies/House M.D. Season 1, episode 21 Tintinalli s Emergency Medicine, A Comprehensive Study Guide, 8 th Ed. CDC December 5, 2008, 57 (RR10);9, Recommendatios and Reports, Appendix A, AIDS Defining Conditions https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a2.htm Oral Manifestations of HIV, www.hiv.va.gov/provider/imagelibrary/oral.asp?post=1&slide=128 A special Differential Diagnosis thank you to the residents and faculty of the MSU/Sparrow Emergency Medicine Residency, especially Dr s Mary Hughes & John Dery ( Everybody Lies ), and Dr Radosveta Wells, TTUHC @ El Paso