Professional Documents
Culture Documents
Richard Usatine, MD
What are causes of sore throats?
Infectious - viral, bacterial, mycoplasma,
chlamydiae, candida
Allergic - allergic rhinitis
Acid Reflux - GERD
Trauma e.g., swallowing a chicken bone
Chemical irritants or burns
Epiglottitis
Thyroiditis
Retropharyngeal abscess
Infectious Causes of
Pharyngitis
Cause Adults
Viral (including mononucleosis) 30-60%
Group A Streptococcus 5-9%
Group C, G, or F Streptococcus 0-18%
N. gonorrhoeae 0-25%
Mycoplasma 10-13%
Chlamydia 9-20%
pooled data from 11 studies
Strep throat versus viral
pharyngitis
ask about: fever, pain on swallowing
physical exam:
throat - exudate, palatal petechiae, injection,
swelling
neck - tender anterior cervical adenopathy
children - strawberry tongue, sand paper
rash
Why do we want to diagnose and
treat GABHS?
to prevent rheumatic fever: less than 200 cases
of acute rheumatic fever per year in the US
to prevent suppurative complications (e.g.,
peritonsillar abscess)
to speed up recovery and shorten duration:
treatment with antibiotics (only if started early in
the clinical course) speeds symptomatic
recovery of patients with culture-proven GABHS
by about a half day
to reduce spread to others
Downside of using antibiotics
T= 38.5
PE: ears - TM's normal
nose clear
neck - no cervical adenopathy
lungs clear
Case 1
What is the differential
diagnosis in order of
likelihood?
Strep
Viral
Sensitivity and Specificity
Strep throat+ Strep throat -
sensitivity specificity
A/(A+C) D/(D+B)
A true positive B false positive
test +
(Hx, PE or lab)
Total = 3
Pretest probability= 35%
What are the tests?
Rapid strep test
Done in minutes in the office
Throat culture
Gold standard how can you get false
negatives or positives?
Acetaminophen
gargling with warm salt water
throat lozenges
fluids, warm or cold, can be soothing
Case 2
A 30 year old man comes to your office with a
scratchy throat and a headache for one day. His
nose is slightly stuffy and he has a non-
productive cough. He denies allergies and
fever. He smokes 1 ppd.
VS : T= 37.1
PE: ears - TM's normal nose clear mucus
and boggy mucosa face - no sinus tenderness
neck - tender adenopathy
Case 2
Total = 2
Pretest probability= 17%
Rapid Strep Test Done
Result is negative
Symptomatic treatment
Case 3
A 6 year old girl is brought to your office with low grade
fever, sore throat, and poor appetite for 3 days. Father
states that she does not have cough or runny nose. No
vomiting or diarrhea. She is allergic to Penicillin.
PE : T = 38.2 P 110
ears - TM's normal
nose - clear
throat - tonsils - beefy red and almost touching in
midline. Uvula in midline, no exudate, no petechiae
neck - enlarged tender anterior cervical nodes
lungs clear
skin - sandpaper rash prominent around axilla
Case 3
Scarlet fever
How do we treat this?
Total = 0
Pretest probability= 1%
What do you do?
No test
No treat no antibiotics
Treat symptoms
Case 5
A 25 year old woman comes to your office with a severe
sore throat for 4 days and has difficulty swallowing. She
now feels very hot and has been off work for 2 days.
Her neck also hurts. She denies cough and rhinitis. No
known allergies. Patient appears to be in moderate
distress but she is able to breath comfortably.
T = 39.5
ears - normal
nose - clear
throat - it is difficult for the patient to open her mouth
because of pain
neck - bilateral anterior cervical adenopathy with right
worse than left
Case 5
Peritonsillar Abscess
Case 6
Total = 4
Pretest probability= 51%
www.med.sc.edu:85/ fox/strep-thr.jpg
Strep Throat
Candida in a
man with AIDS
Viral
Herpangina
Coxsackie A16 Virus
www.netwave.or.jp/~jibika/ herpangina.jpg
Summary
Use of clinical prediction rule to diagnose sore
throat (useful in other diseases)
Clinical prediction rule helps to establish pretest
probability and put patient in one of three
categories
No test, no treat
Test and treat based on result
No test, just treat
Use antibiotics for sore throat when probability of
strep throat is above your treatment threshold
Photographs by:
Richard Usatine, MD for slides 4, 12 and
14
Hospital Practice
Web sites
icarus.med.utoronto.ca/carr/manual/pta.html
Atlas of Infectious Diseases
Useful web sites:
MedRules has the pharyngitis prediction
rule:
http://www.palmgear.com/index.cfm?fuseacti
on=software.showsoftware&prodid=10959