tonsillopharyngitis%20-%20acute
TONSILLOPHARYNGITIS - ACUTE
Patients with group A beta-hemolytic streptococcal pharyngitis have classic symptoms of tonsillar swelling/exudates, tender anterior cervical lymphadenopathy, with no cough but with fever of >38ºC.
Clinical features suggestive of a viral etiology are conjunctivitis, absence of fever, coryza, cough, diarrhea, anterior stomatitis, hoarseness, discrete ulcerative lesions, rhinorrhea and viral exanthem and/or enanthem.
Antibiotics will not be needed for every patient that presents with sore throat but it should not be withheld if the clinical condition is severe or group A beta-hemolytic streptococcus is suspected.

Tonsillopharyngitis%20-%20acute Diagnosis

Diagnosis

Conditions Where Lab Tests for Group A Beta-Hemolytic Streptococci are Not Available or Not Practical

  • Antibiotics will not be needed for every patient that presents with sore throat
  • Antibiotics should not be withheld if the clinical condition is severe or group A beta-hemolytic streptococci (GABS) is suspected
  • Modified Centor score can be used to decide on which patients need no testing, lab tests [throat swab or rapid antigen detection test (RADT)] or empiric antibiotic therapy
    • Score of 0 to 1 does not require testing or antibiotic therapy
    • Patients with score of 2 or 3 require testing, positive results warrant empiric therapy
    • Score of ≥4 is at high risk of GABS and empiric therapy is considered

Who Should be Tested for Group A Beta-Hemolytic Streptococci Pharyngitis?

  • Clinical presentation of group A beta-hemolytic streptococci and viral pharyngitis greatly overlap
  • Patients who have clinical and epidemiological findings suggestive of GABS pharyngitis should be tested for the presence of group A streptococci in the pharynx
  • Diagnostic testing of contacts of infected patients is not routinely recommended

FeverPAIN Score

  • May be used to assess the need to start antibiotic treatment as well as the severity of throat pain
  • High results may indicate streptococcal infection; results should be correlated with Centor criteria score

Centor Criteria

  • Used to assess the susceptibility of patients to GABS infection based on the patient’s age and symptoms
    • Results may assist in the decision to start antibiotic treatment
  • Uses a points system utilizing the following signs/symptoms:
    • Fever (>38°C/>100.4°F) (1)
    • Absence of cough (1)
    • Tender anterior cervical node (1)
    • Tonsillar exudate/swelling (1)
    • Age 3-14 years (1)
    • Age 15-44 years (0)
    • Age >44 years (-1)
  • Modified total risk based on total acute tonsillopharyngitis score:
  • Total Score Risk of GABS
     ≥4 51-53% 
     3 28-35% 
     2  11-17%
     1 5-10%
     ≤0  1-2.5%

 

Laboratory Tests

Throat Swab Culture

  • Gold standard for confirmation of clinical diagnosis of group A beta-hemolytic streptococci (GABS) pharyngitis
    • Recommended for those with history of contact with symptomatic persons with GABS pharyngitis, recurrent GABS infection and symptomatic patients at high risk for rheumatic fever
  • If done correctly, culture of a single throat swab on a blood agar plate has a sensitivity of 90-95%
  • Less expensive than rapid antigen detection test (RADT) and more readily available
  • Results take 24-48 hours
  • Does not differentiate between illness and carrier states
  • False-negative results may be seen in patients who have received antibiotic therapy shortly before or at the time the swab was obtained

Proper Technique of Obtaining a Throat Swab

  • Swab the surface of both the tonsils, tonsillar fossae and posterior pharyngeal wall
  • Do not include the mouth, uvula and oropharynx
  • Optimally done at onset of symptoms and before antimicrobial therapy is started

Rapid Antigen Detection Test (RADT)

  • Developed for the identification of GABS directly from throat swabs
  • More expensive than throat swab cultures, but results are available faster (within minutes)
  • With sensitivity of 80-90% and specificity of 90-99%
  • Does not differentiate between illness and carrier states
  • A rapid test can lead to earlier initiation of definitive therapy with the following advantages:
    • Reduced risk of spread of GABS
    • Reduced acute morbidity associated with illness
    • Earlier return of patient to work or school
  • A negative RADT result for an adult patient does not need to be confirmed with a throat culture because of the low incidence of streptococcal infection and low risk of rheumatic fever in this age group
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Respirology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
21 Nov 2020
Ivermectin confers benefits in the treatment of COVID-19, with a recent study showing that its use helps reduce the risk of death especially in patients with severe pulmonary involvement.
Roshini Claire Anthony, 18 Jun 2020

Endorsement of unproven COVID-19 treatments by high-profile public figures led to a drastic increase in the search and purchase of said treatments in the US, according to a research letter published in JAMA.

Christina Lau, 23 Jun 2020

Patients with coronavirus disease 2019 (COVID-19) have significant gut dysbiosis that persists even after viral clearance and resolution of respiratory symptoms, according to a metagenomic study by the Chinese University of Hong Kong (CUHK). These findings have led to the development of a probiotic supplement expected to be available in a few months.

Elvira Manzano, 12 Dec 2020
Having asthma or allergy does not make COVID-19 severe, a new study presented at ACAAI 2020 has shown.