INFECTIOUS DISEASE REVIEW Upper Respiratory Tract Infections

anterior and/or posterior chain of nodes on the front and back of throat), any temperature elevation is usually
an indication of possible strep throat. Use office strep lysin test to confirm. Keep in mind that the strep lysin
has only about 60% sensitivity (i.e. true positive in strep disease) and 60-95% specificity ( true negative in
health, i.e. if strep not present). About half with a positive strep lysin are actually infected; the rest are strep
carriers who can give the disease to others, but may NOT be acutely infected. Symptomatic contacts of infected
patients should also probably be evaluated for strep throat.
Acute Pharyngitis-inflammatory process of pharynx and tonsils (Waldeyer's ring) "sore throat" NOTE: always
check ears and sinuses when a patient complains of (c/o) sore throat!
Pharyngitis is more common in cold and flu seasons (may precede cold)
CONCEPT: Some 70-90% or more of sore throats are viral (at least to start).
Viral bugs - rhinovirus, parainfluenza, coronavirus, adenovirus, Herpes simplex and influenza.
Viral pharyngitis Symptoms-nasal Symptoms and cough usually present, sore throat may not be main
complaint but has "cold" and/or hay fever or allergy ; rarely systemic complaints of muscle or joint aches (e.g.
arthralgias or myalgias) unless its the flu
NOTE: VIRAL can quickly go to bacterial sore throat in immune compromised pts.; more slowly or if viral
precedes (always suspect if viral lasts longer than 2-3 days) or low-grade fever starts, with anterior chain
lymphadenopathy, or stomach ache in younger as well as older patients.
Bacterial bugs - S. pyogenes, H. flu, Chlamydia or Mycoplasma pneumoniae, N. gonorrhea (if STD check GU &
GI also)
Bacterial pharyngitis Symptoms - Sore throat primary complaint, painful cervical lymphadenopathy (swollen
anterior neck chain nodes; posterior also if OM/Sinusitis), elevated WBC count with "Shift to the left" and fiery
red throat with exudate on pharynx and tonsil/adenoids. In children and some adults stomach pain may be a
frequent complaint with Strep throat. See picture below for classic appearance.
Differentiate Strep pharyngitis by rapid screening (Strep lysin), but only 60-95% sensitivity (positive in disease
and 90-95 % specificity (negative in healthy state)-- and throat culture for Strep: NOTE only half of positive pts.
are actually infected' rest are presumably carriers of S. pyogenes. Always check that contacts of infected pts.
have been evaluated (e.g. siblings, classmates, friends and parents/guardians).
Acute Treatment – Generally use standard pen V, amoxicillin, procaine or Benzathine Pen G, Pen G PO (doubledose
of V), most beta lactams (except 3rd generation cephalosporins) and macrolides (erythromycin,
clarithromycin (Biaxin), azithromycin (Zithromax) work for Streptococcus. AVOID: same as for otitis media
(OM)-NOTE: if OM is also present pen V may not be effective. Many ID specialists prefer amoxicillin with or
without clavulanate (Augmentin). Moxatag is a new, extended-release amoxicillin for once a day usage. The
objective of treatment is to prevent heart and joint (scarlet and rheumatic fever) but not kidney damage (strep
glomerulonephritis).
CASE 4- A 35 year-old female (yof) presents with a sore throat and wants to know what gargle to use. Her
throat is in the picture below.
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