Pharyngitis natural history, complications and prognosis: Difference between revisions
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==Natural History== | ==Natural History== | ||
Acute pharyngitis is typically described as the triad of sore throat, fever, and pharyngeal inflammation characterized by erythema and edema, although exudates, vesicles, or ulcerations may also be present. Although pharyngitis may be a primary disorder, sore throat and pharyngeal erythema may also be prominent in systemic disorders, such as the acute retroviral syndrome, or part of a more generalized upper respiratory tract infection. Most cases of acute pharyngitis are due to common viral infections and are benign, self-limited processes. The appropriate recognition of patients with more complicated infections that require diagnostic evaluations and treatment is one of the challenges of primary care medicine.<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> An estimated 1-2% of acute pharyngitis progresses to recurrent or chronic disease.<ref name="pmid16970213">St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16970213 Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes.] ''Mayo Clin Proc'' 81 (9):1172-6. PMID: [https://pubmed.gov/16970213 16970213]</ref> Patients with recurrent episodes of pharyngitis and >1 episode of streptococcal pharyngitis at close intervals associated with laboratory evidence of GAS pharyngitis consider that they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.<ref name="pmid23091044">Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23091044 Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.] ''Clin Infect Dis'' 55 (10):1279-82. [http://dx.doi.org/10.1093/cid/cis847 DOI:10.1093/cid/cis847] PMID: [https://pubmed.gov/23091044 23091044]</ref> | Acute pharyngitis is typically described as the triad of sore throat, fever, and pharyngeal inflammation characterized by erythema and edema, although exudates, vesicles, or ulcerations may also be present. Although pharyngitis may be a primary disorder, sore throat and pharyngeal erythema may also be prominent in systemic disorders, such as the [[Human Immunodeficiency Virus (HIV)|acute retroviral syndrome]], or part of a more generalized [[upper respiratory tract infection]]. Most cases of acute pharyngitis are due to common viral infections and are benign, self-limited processes. The appropriate recognition of patients with more complicated infections that require diagnostic evaluations and treatment is one of the challenges of primary care medicine.<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> An estimated 1-2% of acute pharyngitis progresses to recurrent or chronic disease.<ref name="pmid16970213">St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16970213 Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes.] ''Mayo Clin Proc'' 81 (9):1172-6. PMID: [https://pubmed.gov/16970213 16970213]</ref> Patients with recurrent episodes of pharyngitis and >1 episode of streptococcal pharyngitis at close intervals associated with laboratory evidence of GAS pharyngitis consider that they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.<ref name="pmid23091044">Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23091044 Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.] ''Clin Infect Dis'' 55 (10):1279-82. [http://dx.doi.org/10.1093/cid/cis847 DOI:10.1093/cid/cis847] PMID: [https://pubmed.gov/23091044 23091044]</ref> | ||
=== '''Group A Streptococcus''' === | === '''Group A Streptococcus''' === | ||
Strep pharyngitis occurs predominantly, though not exclusively, in school-age children.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref> Symptoms develop after a short incubation period of 24 to 72 hours.<ref name="pmid15053411">Vincent MT, Celestin N, Hussain AN (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15053411 Pharyngitis.] ''Am Fam Physician'' 69 (6):1465-70. PMID: [https://pubmed.gov/15053411 15053411]</ref> | Strep pharyngitis occurs predominantly, though not exclusively, in school-age children.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref> Symptoms develop after a short incubation period of 24 to 72 hours.<ref name="pmid15053411">Vincent MT, Celestin N, Hussain AN (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15053411 Pharyngitis.] ''Am Fam Physician'' 69 (6):1465-70. PMID: [https://pubmed.gov/15053411 15053411]</ref> All patients may not have the full-blown syndrome and many patients are milder and nonexudative, and patients who have undergone tonsillectomy may have milder symptoms.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref> Untreated, [[Group A beta-hemolytic streptococci|group A bete hemolytic streptococcus]] (GABHS) infection lasts seven to 10 days. Patients with untreated streptococcal pharyngitis are infectious during the acute phase of the illness and for one additional week. Effective antibiotic therapy shortens the infectious period to 24 hours, reduces the duration of symptoms by about one day, and prevents most complications.<ref name="pmid15053411" /> | ||
=== Corynebacterium diphtheriae === | === Corynebacterium diphtheriae === | ||
The disease occurs primarily among unimmunized or poorly immunized members of socioeconomically disadvantaged groups.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>The incubation period for Corynebacterium diphtheriae infection is two to four weeks.<ref name="pmid15053411" /> | The disease occurs primarily among unimmunized or poorly immunized members of socioeconomically disadvantaged groups.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>The incubation period for [[Corynebacterium diphtheriae]] infection is two to four weeks.<ref name="pmid15053411" /> | ||
==Complications== | ==Complications== | ||
Identifying the cause of pharyngitis, especially | Identifying the cause of pharyngitis, especially [[Group A streptococcal infection|GABHS]], is important to prevent potential life-threatening complications.<ref name="pmid15053411">Vincent MT, Celestin N, Hussain AN (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15053411 Pharyngitis.] ''Am Fam Physician'' 69 (6):1465-70. PMID: [https://pubmed.gov/15053411 15053411]</ref> Serious complications of pharyngitis may include [[peritonsillar abscess]] or [[retropharyngeal abscess]].<ref>{{cite book | last = Cohen | first = J | title = Infectious diseases | publisher = Mosby/Elsevier | location = Edinburgh | year = 2010 | isbn = 978-0323045797 }}</ref> Complicationsof [[pharyngitis]] based on the causing agent include the following: <ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589 }} </ref> | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2] Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [3]
Overview
The sore throat, fever, and malaise associated with acute pharyngitis are distressing, but with few exceptions, these illnesses are both benign and self limited. Many bacterial and viral organisms are capable of inducing pharyngitis, either as a single manifestation or as part of a more generalized illness.[1] History and symptoms are essential to diagnosis to identify the treatable causes (e.g., GAS) to prevent complications.[2]
Natural History
Acute pharyngitis is typically described as the triad of sore throat, fever, and pharyngeal inflammation characterized by erythema and edema, although exudates, vesicles, or ulcerations may also be present. Although pharyngitis may be a primary disorder, sore throat and pharyngeal erythema may also be prominent in systemic disorders, such as the acute retroviral syndrome, or part of a more generalized upper respiratory tract infection. Most cases of acute pharyngitis are due to common viral infections and are benign, self-limited processes. The appropriate recognition of patients with more complicated infections that require diagnostic evaluations and treatment is one of the challenges of primary care medicine.[3] An estimated 1-2% of acute pharyngitis progresses to recurrent or chronic disease.[4] Patients with recurrent episodes of pharyngitis and >1 episode of streptococcal pharyngitis at close intervals associated with laboratory evidence of GAS pharyngitis consider that they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.[5]
Group A Streptococcus
Strep pharyngitis occurs predominantly, though not exclusively, in school-age children.[1] Symptoms develop after a short incubation period of 24 to 72 hours.[6] All patients may not have the full-blown syndrome and many patients are milder and nonexudative, and patients who have undergone tonsillectomy may have milder symptoms.[1] Untreated, group A bete hemolytic streptococcus (GABHS) infection lasts seven to 10 days. Patients with untreated streptococcal pharyngitis are infectious during the acute phase of the illness and for one additional week. Effective antibiotic therapy shortens the infectious period to 24 hours, reduces the duration of symptoms by about one day, and prevents most complications.[6]
Corynebacterium diphtheriae
The disease occurs primarily among unimmunized or poorly immunized members of socioeconomically disadvantaged groups.[1]The incubation period for Corynebacterium diphtheriae infection is two to four weeks.[6]
Complications
Identifying the cause of pharyngitis, especially GABHS, is important to prevent potential life-threatening complications.[6] Serious complications of pharyngitis may include peritonsillar abscess or retropharyngeal abscess.[7] Complicationsof pharyngitis based on the causing agent include the following: [8]
| Common complications | ||
| Pathogen | Complications | |
|---|---|---|
| Group A Streptococcus |
Suppurative complications
Non suppurative complications
| |
| Influenza |
| |
| Adenovirus |
| |
| Cocksackie A virus |
| |
| Ebstein barr virus |
| |
| Less common complications | ||
| Gonococcus |
| |
| Diphtheria |
| |
| Heamophilis influenza | ||
| Fusobacterium necrophorum | ||
| Parainfluenza virus |
| |
Group A Streptococcal Pharyngitis Complications
Rheumatic fever
Rheumatic fever is exceedingly rare in the United States and other developed countries (annual incidence less than one case per 100,000). This illness should be suspected in any patient with joint swelling and pain, subcutaneous nodules, erythema marginatum or heart murmur, and a confirmed streptococcal infection during the preceding month. Patients will have an elevated antistreptolysin- O titer and erthrocyte sedimentation rate.[6]
Post streptococcal glomerulonephritis
Post streptococcal glomerulonephritis is another rare complication of GABHS pharyngitis, although treatment with antibiotics does not prevent it. Patients present with hematuria and, frequently, edema in the setting of a recent streptococcal infection with an elevated antistreptolysin-O titer.[6]
Scarlet fever
Scarlet fever is associated with GABHS pharyngitis and usually presents as a punctate, erythematous, blanchable, sandpaperlike exanthem. The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia’s lines). The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue).
Prognosis
Most cases of pharyngitis go away on their own without complications.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes. Mayo Clin Proc 81 (9):1172-6. PMID: 16970213
- ↑ Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55 (10):1279-82. DOI:10.1093/cid/cis847 PMID: 23091044
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Vincent MT, Celestin N, Hussain AN (2004) Pharyngitis. Am Fam Physician 69 (6):1465-70. PMID: 15053411
- ↑ Cohen, J (2010). Infectious diseases. Edinburgh: Mosby/Elsevier. ISBN 978-0323045797.
- ↑ 8.0 8.1 8.2 8.3 Murray RC, Chennupati SK (2012). "Chronic streptococcal and non-streptococcal pharyngitis". Infect Disord Drug Targets. 12 (4): 281–5. PMID 22338589.