E-CASE # 10

March 12-16

Jane Yeh, M.D.

43 year old man presents with 4 days of sore throat and runny nose. He reports fevers and chills. He denies any chest pain, shortness of breath, abdominal pain, vomiting, or diarrhea.

PMH: HTN and asthma

Meds: HCTZ 25 mg po qd, Albuterol prn

PE:

• General- tired appearing, NAD

• VS- T 99.6, BP 145/67, P 89, R 18, O2 sat 97%

• HEENT- NC/AT, PERRL, EOMI

• O/P: slightly erythematous, no exudate

• Neck- supple, +ant cervical LAN

• CV- RRR, no m/r/g

• Lungs- CTA B

• Abd- soft, nt, nd, nl BS

• Extrem- no edema

• Labs: wbc 7

• Rapid strep negative

• CXR: no infiltrates

Questions

1. What are the causes of pharyngitis?

2. What clinical signs are most indicative of strep pharyngitis?

3. What is the sensitivity of the rapid Strep test?

4. Which antibiotics can be used for treatment of Group A Strep?

Ecase #11 Discussion

1. Group A Streptococcus is the most common bacterial cause. Other causes include Groups C and G streptococcus, diphtheria (toxin from Corynebacterium diphtheriae). Arcanobacterium haemolyticum, and Neisseria gonorrhoeae. Viral causes include rhinovirus, EBV (mononucleosis) adenovirus, coxsackie virus, and acute HIV.

2. The most common symptoms of Strep pharyngitis include fever, sudden onset, headache, abdominal pain, nausea, and vomiting.. Physical findings include erythema, exudates, soft palate petechiae, anterior cervical lymphadenopathy, and scarlatiniform rash.

3. Sensitivity of the rapid test is approximately 80-90%. The gold standard is a culture which has a sensitivity of greater than 90%. Both the rapid strep and the culture are fairly specific. However, they cannot differentiate between colonization and actual disease. A possible algorithm is to treat if the rapid strep is positive without sending the culture given the specificity of the rapid strep. If the rapid strep is negative, one can send the culture. In a compliant patient population, one can wait the result of the culture (1-2 days) before treatment. Delay of treatment usually will not affect the rate of complications (such as retropharyngeal abscess, peritonsillar abscess, or acute rheumatic fever).

4. Group A Strep is sensitive to penicillin. Penicillin V for 10 days can be used. Other treatment options include a single shot of Benzathine penicillin 1.2 million units. Erythromycin for 10 days or azithromycin for 5 days are options for those who are penicillin-allergic. Cephalosporins may also be used.

Reference

Bisno AL. Acute Pharyngitis. New England Journal of Medicine. 2001; 344: 205-211.