Слайд 1Differential diagnosis of pharyngitis
Слайд 2Main inflammatory throat diseases
Pharyngitis
Tonsillitis, tonsillopharyngitis
Adenoiditis
Paratonsillar abscess
Retropharyngeal abscess
Слайд 3Classification of pharyngitis
Catarrhal pharyngitis
- viral
infections
Exudative pharyngitis
- at viral
infections (adenovirus, ЕВV)
- purulent-exudative (GAS)
Membranous pharyngitis
Diphtheria
Пpseudomembranous pharyngitis
EBV infection
Lysteriosis
Syphilis
Leukemia
Burnt pharyngitis
Oropharyngeal candidosis
Herpetic pharyngitis (НSV, enterovirus)
Слайд 4Non-infectious pharyngitis
SLE
Kawasaki Syndrome
Stivens-Johnson syndrome
Leukemia
Radiation damage
Burnt pharyngitis
Слайд 5Etiology of infectious pharyngitis
Bacteria (35-30 %)
Group A Streptococcus (65-80%)
Group C
and G Streptococcus (5-10 %)
Arcanobacterium haemolyticum
Neisseria gonorrheae
Corynebacterium diphtheriae
Mycoplasma pneumoniae
Chlamydia pneumoniae
Francisella
tularensis
Coxiella burnetii
Viruses (65-70 %)
Rhinovirus
Adenovirus
Epstein-Barr virus
Influenza
Parainfluenza
Enterovirus
Herpes simplex virus
Coronavirus
RS-virus
Слайд 6Clinics of viral pharyngitis
Catarrhal pharyngitis
Moderate sore throat, dryness
Moderate pharyngeal hyperemia
-
Follicular tonsillar hyperplasia
- Serous exudate (+/-) at adenoviral and EBV
infections
Presence of other catarrhal signs: cough, rrhynitis, conjunctivitis
Moderate fever
Disease course 3-7 days
Слайд 8Pharyngitis at primary HIV infection
Incubation period is 3 to 5
weeks
Catarrhal pharyngitis sometimes with ulcers
Lymphadenopathy week before fever and
pharyngitis
Other signs of HIV infection: arthralgias, myalgias, macule-papule rash, drowsiness
Слайд 9Pharyngitis at enteroviral infection
Common signs:
Season – summer (“summer flu”)
High fever
Mild
pharyngeal hyperemia
Not typical:
- tonsillar
exudate,
- cervical lymphadenitis
Specific oropharyngeal signs :
- herpangina – Сoxsackievirus A, B, Echovirus
(papule-vesicles or nodules with hyperemia around on posterior pharyngeal wall, 1-2 mm, with further ulcers and disappearance 5-7 days later)
- “hand-foot-mouth disease” - coxsackievirus A 16
(painful vesicles or ulcers in mouth cavity, on palms and soles; fever subfebrile)
Слайд 10Herpangina at enteroviral infection
Слайд 11“Hand-foot-mouth disease” coxsackievirus A 16
Слайд 12Primary herpetic gingivostomatitis
Cause: HSV-1,2
In children under 5 years
High fever
Intense mouth
pain (possible dehydration)
Ulcers in mouth: on lips, posterior pharynx, soft
and hard palate
Disease course 1-2 weeks
Слайд 17Epidemiology of GAS
Source: sick, carrier
Ways of transmission:
Airborne, food-borne,
watery
Season: Spring – Summer
Susceptible group:
children of 5-15
years
Слайд 18Streptococcal (GAS) infection
Classification of GAS – associated diseases
1. Purulent diseases:
- respiratory infections;
- skin and soft tissue infections;
- systemic purulent infections.
2. Toxin – mediated infections (scarlet fever, TSS, erysipelas).
Infectious – allergic complications (rheumatic fever, carditis, glomerulonephritis, PANDAS)
Слайд 19Streptococcal pharyngitis
Associated with hemolytic Streptococcus of groups А, С, G
Fever
39.5 С and higher, chills
Prominent throat pain and difficulty of
swallowing
PE: “burning throat”, uvualr edema, Yellowish purulent covers in lacunas or tonsillar follicules
“Strawberry tongue” (papules + color)
Tense and painful tonsillar lymph nodes
Слайд 23Laboratory diagnosis of streptococcal pharyngitis
Strep culture
Reaction with bacitracin (inhibit
growth of only GAS)
Express tests: lattex agglutination, co-agglutination (Strep-test )
– determination of group polysaccharide antigen
Detection of GAS DNA – (PCR, DNA-hybridization )
Titer of anti-streptolysin O – 2-3 weeks later. Diagnostic titer - 1:300
Слайд 24GAS
is the only widely spread etiology of pharyngitis which
requires antibiotic therapy
Слайд 25Antibiotics at streptococcal pharyngitis
Penicillins (oral, parnetheral)
Cephalosporins of 1-2 generation
Macrolides
Слайд 26EВV infection
Infectious mononucleosis
Слайд 27Infectious mononucleosis is caused by Epstain-Barr virus and is characterized
by:
Intoxication
Acute tonsillitis
Generalized polylymphadenopathy,
Hepatosplenomegaly
Слайд 28Diseases with mononucleosis-like syndrome
ЕВV infection – 90%
(infectious mononucleosis)
СМV infection
(cytomegaloviral mononucleosis)
HIV infection
Rubella
Toxoplasmosis
Viral hepatitis
Слайд 29Etiology of EBV
Family Herpesviridae – IV type
DNA-containing
Target cells -
В- and Т- lymphocytes
Life-long persistense in B-cells
Oncogenic (Berkitt’s lymphoma,
nasopharyngeal carcinoma, CNS lymphoma at HIV infection)
Слайд 30Epidemiology of EBV infection
Way of transmission:
contact (saliva),
sexual, hemotransfusions
Children under 5 years – 80 %
In 50 %
asymptomatic
After infection the person excretes the virus during 6 months; after – periodically through the life
Слайд 31Pathogenesis of EBV infection
Penetration and viral replication in pharyngeal mucosa
Viremia
Infection of peripheral B-lymphocytes
Uncontrolled prolipheration of B-cells (CBC – absolute
lymphocytosis and ESR)
Responsive production of T-cells supressors (СД8+) for inhibition of B-cell proliferation (CBC – atypical mononuclears)
Depression of cellular immunity
Слайд 32Clinics of EBV infection
Fever
Lymphadenopathy
Exudative pharyngitis (prominent)
Adenoiditis, nasal obstruction
Hepatomegaly
Possible
exanthema
Слайд 34Pharyngitis at infectious mononucleosis
Слайд 35Pharyngitis at infectious mononucleosis
Слайд 36Pharyngitis at infectious mononucleosis
Слайд 37Complications of EBV infection
Respiratory tract obstruction (5-8%)
Splenic rupture (0,5%)
Neurologic disturbances:
- seizures,
- Alice in Wonderland (metamorphopsia),
- transverse myelitis,
- facial paralysis,
- meningitis (monocytic cytosis)
Hematological:
- hemolytic and aplastic anemia,
- thrombocytopenia,
- neutropenia (2-3rd wk of the disease)
Слайд 38Laboratory diagnosis of EBV infection
Heterophylic test (antibodies)
in children
older 6 years (1:28 - 1:56)
Serologic – antibodies to
early, capsid and nuclear antigens
CBC:
leucocytosis (leucopenia), lymphocytosis, atypical mononuclears, accelerated ESR.
Increased activity of ALT
Слайд 39Serological profile of EBV infection
Слайд 40Therapy of EBV infection
NSAIDs (acetaminofen, ibuprofen) for fever
Corticosteroids (on indications)
Acyclovir
– questionable.
Marcolides – for exudative purulent pharyngitis. Azythromycin 10 mg/kg/day
– 5 days
N.B.! Amoxicillin (ampicillin) is contraindicated
Слайд 41Indications for corticosteroid therapy
Airway obstruction
Autoimmune hemolytic anemia
Thrombocytopenia
Hemorrhagic syndrome
Seizures
Meningitis
Слайд 4225%-30% in childhood
Most common – GAS
Possible joining of anaerobic bacteria
Paratonsillar
abscess
Слайд 43Symptoms
Throat pain / dysphagia
5-7 days
No effect from antibiotics
Trismus
Pain at mouth opening
Fever
Muffled voice
Pain irradiation into ear
Слайд 44Oropharyngeal signs
Assymetrical edema of soft tissue around tonsils with tonsillar
dislocation
Fluctuation by palpation
Tonsils can be normal, or hyperemic, or covered
with axudate
Uvula is dislocated to healthy side
Soft palate is hyperemic and edemstous
Bilateral tonsillar involvement in 3%
Malodor from mouth
Cervical lymphadenopathy
Слайд 45Treatment
Penicillin G benzathine :
Adults - 600 mg (~1 million
U) IV q6h
Children -12,500-25,000 U/kg IV q6h + Metronidazole
(Flagyl) 15 mg/kg or 1 g per 70-kg adults IV during 1 hour
supportive dosage: 6 h infusion 7.5 mg/kg or 500 mg per 70-kg adults during 1 hour every 6-8h; not more than 4 g/d
Clindamycin – infants and children : 15-25 mg/kg/d PO every 8h; 25-40 mg/kg/d IV/IM every 8h
Erythromycin
Слайд 46Diphtheria
Acute anthroponous disease, caused by Gram(+) toxigenic bacillus Corynebacterium diphtheria,
characterized by local fibrinous-inflammation of the mucus and/or skin, general
intoxication and toxic complications: myocarditis, polyneuritis, nephrosis
Слайд 47Etiology of diphtheria
Gram(+) aerobic bacillus. Non-motile, non-encapsulated. Three variants: MITIS,
GRAVIS and INTERMEDIUS.
All variants of toxigenic Corynebacterium produce identical
toxin.
Non-toxigenic forms of Corynebacterium do not cause disease.
Corynebacterium is resistant to low and high temperatures and drying.
Situated in “X” or “V” pairs
Corynebacterium can be resistant to erythromycin
Слайд 48Epidemiology of diphtheria
Season – cold
Source – sicka and carriers
Transmission
– airborne
70% population vaccination prevents epidemics
Слайд 50Classification of diphtheria
Diphtheria of tonsils
Diphtheria of nose
Diphtheria of larynx (croup,
laryngitis)
Diphtheria of eye
Diphtheria of skin
Слайд 51Clinics of diphtheria
Incubational period = 2-10 days
Acute disease onset
Intoxication:
moderate fever, headache, weakness
Fibrinous pharyngitis
Anterior cervical lymphadenitis
Subcutaneous cervical tissue
edema (+/-)
Слайд 52Membranous pharyngitis
Cyanotic hyperemia of pharynx
Tonsillar edema
Thick whitish-grayish covers, removed with
bleeding of mucosa
Are formed by 3rd day of diphtheria
Слайд 57Symptoms of severe diphtheria
Toxic neck edema
Hemorrhagic syndrome
Shock (tachycardia, hypotension, oliguria)
Слайд 59Complications of diphtheria
Myocarditis
Neuropathies
Nephritis
Слайд 60Diagnosis of diphtheria
Culture of С.diphtheriae with detection of toxigenicity
Detection
of antibodies in reaction of neutralization (protective level is 0,5
U\ml)
Detection of antibodies in reaction of direct hemagglutination (protective level is 1:320)
Detection of phage (PCR)
Detection of toxin in blood serum
CBC: leucocytosis, neutrophilosis, accelerated ESR
At neuropathies – elevation of protein in CSF
Слайд 61Therapy of diphtheria
Antitoxin (serum):
Minimal dosage: 20
- 40 thousand U
Maximal dosage: 150
thousand U
Route of injection: IM, IV
Antibiotics
(erythromycin, penicillin - 14 days)
Слайд 62Prophylaxis of diphtheria
Vaccination with diphtheria anatoxin
- V1: 3,
4, (+\-) 5 months
- V2: 15 - 18 months
-
V3: 4 - 6 years
- Later – every 10 years
Слайд 63Prophylaxis of contacts and carriers
Erythromycin or penicillin -7 days
Booster dose
of anatoxin
Throat culture
Control throat culture 24 hours after antibiotic course
