Current Issues in Pharyngitis: Carlos A. Arango, M.D., F.A.A.P. Assistant Professor Department of Pediatrics University of Florida

Current Issues in Pharyngitis: Carlos A. Arango, M.D., F.A.A.P. Assistant Professor Department of Pediatrics University of Florida

Pharyngitis Inflammation of any structures of the pharynx Common cause of upper respiratory tract in children Diagnosed ~ 7 million times yearly

Etiologic Agents Viruses Epstein-Barr Virus Adenovirus Enteroviruses Herpes Simplex virus Influenzae virus Rhinoviruses Coronavirus RSV Bacteria Streptococcus (A,C,G) Arcanobacterium hemolyticum Corynebacteria diphteriae Neisseria gonorrheae Chlamydia pneumoniae Mycoplasma pneumoniae Yersinia enterocolitica Francisellla tularensis Coxiella burneii

Group A Streptococcus (GAS) Late winter-early spring Transmission: Inhalation of large droplets Direct contact Incubation period: 2-5 days Abx eliminate contagiousness within 24 h

Clinical Features of GAS Fever Malaise Headaches Sore throat Abdominal pain Nausea Vomiting

Physical Findings of GAS Red pharynx Petechiae in palate Cervical adenopathy Strawberry tongue

Scarlet Fever Rash Erythrogenic exotoxin A Sand paper-like Circumoral pallor Pastia sign Desquamation

Diagnosis GAS Rapid Antigen Tests Sensitivity ~ 75% Specificity ~95% Throat Culture Bacitracin disk

Diagnosis cont. Serologic Evaluation ASO anti-dnase B Anti-Hyaluronidase ESR CRP

Treatment Reduction of sequelae Suppurative Non-suppurative Retropharyngeal abscess Peritonsillar abscess Cervical adenitis Acute Otitis Media Acute rheumatic fever Mastoiditis Acute phyelonephritis Sinusitis Reactive arthritis Bacteremia

How Bacteria Defend Against -Lactam Antibiotics -Lactam enzymes inactivate -lactam antibiotics Peptidoglycan cell wall Plasma membrane -Lactam antibiotics do not bind as well to altered PBPs Altered PBPs Cytoplasm Reduced cell wall permeability inhibits antibiotic entry Antibiotic -Lactamase Chambers HF. In: Principles and Practice of Infectious Diseases. 2000:261-274. Opal SM et al. In: Principles and Practice of Infectious Diseases. 2000:236-253.

Treatment Penicillin (drug of choice) Universally sensitive Poor compliance Failure to eradicate GAS from pharynx 15% Amoxicillin Better taste Ease of use Clinical / Bacteriologic treatment failure Poor compliance Tolerance of GAS to PNC β-lactamase producing oral flora Lack of bacteriocins by -streptococci, thus inhibiting colonization of GAS

How Bacteria Defend Against Macrolides Bacteria alter macrolide binding site (ermam gene, MLS B phenotype) Macrolide unable to block protein synthesis Bacteria activate efflux pumps (mefe gene, M phenotype) Macrolide excreted from cell Ribosomes 50 30 50 30 50 30 Cytoplasm Macrolide Weisblum B. In: Gram-Positive Pathogens. 2000:694-710. Hyde TB et al. JAMA. 2001;286:1857-1862.

Treatment cont. Macrolides Allergic to PNC Resistance pattern increasing Spain 2002 GAS resistance 529 isolates=>417 TCx (78%)=>435 children 100% susceptible to PNC, Cefprozil 157 (30%) resistant to E/A, 1.3% C

Treatment cont. Cephalosporins Effective against group A streptococci Effective against -lactamase producing H. influenzae, M. catarrhalis and S. aureus Superior efficacy due to 2 phenomena: Beta-lactamase producing bacteria NO interference with alpha hemolytic streptococci Inhibits colonization of GAS Sensitive to PNC, relative resistance to cephalosporins Excellent 2 nd line of choice for treating GAS pharyngotonsillitis

Chronic Pharyngeal Carriers Persistent colonization 8.3% (+ TCx) Confounding factors in diagnosis When to treat? Sign and symptoms of pharyngitis Rapid test or culture positive Elevated streptococcal antibodies Use appropriate antibiotic

cont Reserve special antibiotics Anxious patient or family Hx of ARF Works in hospital, nursing homes ping-pong spread among family members Benzathine Penicillin + Rifampin Clindamycin

Infectious Indications for Tonsillectomy Hyperplastic lymphoid tissue Disproportionate amount of space occupied

Tonsillectomy cont Upper Airway Resistance Syndrome Mouth breathing Snoring Gasping Sleep pauses Restless sleep Enuresis Obstructive Sleep Apnea Syndrome > 20 sec pause 5-10 episodes/hour Cor pulmonale Polysommnography

Indications for Tonsillectomy cont Dysphagia Speech impairment Halitosis Recurrent/chronic pharyngotonsillitis 7 episodes/year 5 episodes/2 years 3 episodes/3 years Peritonsillar abscess Hemorrhagic tonsillitis Tonsil asymmetry vs Malignancy Adenopathy > 3cm Dysphagia Night sweats Fevers PANDAS

PANDAS Pediatric Auto-immune Neuropsychiatric Disorder Associated Streptococcal infection

PANDAS GAS triggers abrupt neuro-behavioral symptoms TICS/OCD Auto-antibodies GAS cross react with neuronal cells Does PANDAS exist?

Case 1 9 year old male with recurrent tonsillitis 3 documented GAS tonsillitis, 4 last year TS (motor/vocal tics) for past year Symptoms worsened with each episode of tonsillitis ASO 170 U (nl <170) T&A performed=>2 months later almost free of tics

Case 2 Brother of 1 st case 10 years old Recurrent tonsillitis (5 documented/year) OCD and anxiety disorder T&A performed 3 weeks later playing outside (afraid of leave home due to OCD)

Sydenham s Chorea (SC) and GAS

SC and GAS Autoimmune process in RF with antimyocardial antibodies Anti-GAS Ab cross-react CNS neurons This autoantibodies found healthy subjects

PANDAS and Sydenham s chorea Chorea involving face and extremities Motor and vocal tics Carditis (30-60%) Elevated ASO (80%) Clearly association with GAS D8/17 Ab on surface of B lymphocyte Ayoub et-al

PANDAS and Tourette Syndrome (TS) Involuntary chronic motor/vocal tics Tics exacerbates by stress, anxiety Co-morbid neurobehavioral problem OCD, ADHD,anxiety

PANDAS and GAS Swedo (1998) 50 children Premorbid personality Early age tics(6.3+2.3), OCD(7.4+2.7)years Relapsing-remitting pattern Dramatic/acute symptom exacerbation with relative quiescent Association with GAS (72%) Tics BEFORE infection-related exacerbation should EXCLUDE diagnosis PANDA (Sweto et al)

DSM IV Tics/OCD (preexisting tics should exclude diagnosis) Prepuberal disorder Sudden, explosive onset/worsening of tics positive ASO obtained at time of single exacerbation are not sufficient to prove that a child has PANDAS Swedo et al. Continue monitoring