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2. Respiratory diseases
Acute pharyngitis
A cute inflam m ation of th e tonsils and ph arynx. T h e m ajority of cases are of v iral orig 2in
and d o not require antibiotic treatm ent.
G roup A streptococcus is th e m ain bacterial cause, and m ainly affects ch ild ren ag e 3 to
1 4 years. A cute rh eum atic fev er, a serious late com plication of streptococcal
ph aryng itis, is com m on in d ev eloping countries, and can be prev ented w ith antibiotic
th erapy.
O ne of th e m ain objectiv es in assessing acute ph aryng itis is to id entify patients
requiring antibiotic treatm ent.
Clinical features
– F eatures com m on to all types of ph aryng itis:
T h roat pain and d ysph ag ia (d ifficulty sw allow ing ), w ith or w ith out fev er.
– Specific features, d epend ing on th e cause:
C om m on form s:
• Erythematous (red th roat) or exudative (red th roat and w h itish exud ate) pharyngitis:
Since th is appearance is com m on to both v iral and streptococcal ph aryng itis, oth er
criteria sh ould be consid ered to d isting uish betw een th em :
I n ch ild ren und er 3 years, streptococcal ph aryng itis is rare and ph aryng itis is
alm ost exclusiv ely v iral.
I n ch ild ren from 3 to 1 4 years, th e presence of at least 3 of th e 4 follow ing features
[absence of coug h , fev er abov e 3 8 °C , at least one enlarg ed and tend er anterior
cerv ical lym ph nod e, presence of an exud ate] fav ours streptococcal ph aryng itis.
C onv ersely, presence of coug h , runny nose, conjunctiv itis or enlarg ed posterior
cerv ical lym ph nod es fav ours v iral ph aryng itis.
I n patients ov er 1 4 years, th e probability of streptococcal ph aryng itis is low .
I nfectious m ononucleosis (I M ) d ue to th e E pstein-B arr v irus sh ould be suspected in
ad olescents and young ad ults w ith extrem e fatig ue, g eneralized ad enopath y and
often splenom eg aly.
E ryth em atous or exud ativ e ph aryng itis m ay also be associated w ith g onococcal or
prim ary H I V infection. I n th ese cases, th e d iag nosis is m ainly prom pted by th e
patient's h istory.
• Pseudomembranous pharyngitis ( red tonsils/ ph arynx cov ered w ith an ad h erent
g rayish w h ite false m em brane) : see diphtheria, pag e 5 5 .
L ess com m on form s:
• Vesicular pharyngitis (clusters of tiny blisters on th e tonsils): alw ays v iral (coxsackie
v irus or prim ary h erpetic infection).
• Ulcero-necrotic pharyngitis: h ard and painless syph ilitic ch ancre of th e tonsil;
tonsillar ulcer soft on palpation in a patient w ith poor oral h yg iene and
m alod orous breath (V incent tonsillitis).
– L ocal com plications:
P eritonsillar abcess: fev er, intense pain, h oarse v oice, trism us (lim itation of m outh
opening ), unilateral d ev iation of th e uv ula.
53
Acute pharyngitis
A cute inflam m ation of th e tonsils and ph arynx. T h e m ajority of cases are of v iral orig 2in
and d o not require antibiotic treatm ent.
G roup A streptococcus is th e m ain bacterial cause, and m ainly affects ch ild ren ag e 3 to
1 4 years. A cute rh eum atic fev er, a serious late com plication of streptococcal
ph aryng itis, is com m on in d ev eloping countries, and can be prev ented w ith antibiotic
th erapy.
O ne of th e m ain objectiv es in assessing acute ph aryng itis is to id entify patients
requiring antibiotic treatm ent.
Clinical features
– F eatures com m on to all types of ph aryng itis:
T h roat pain and d ysph ag ia (d ifficulty sw allow ing ), w ith or w ith out fev er.
– Specific features, d epend ing on th e cause:
C om m on form s:
• Erythematous (red th roat) or exudative (red th roat and w h itish exud ate) pharyngitis:
Since th is appearance is com m on to both v iral and streptococcal ph aryng itis, oth er
criteria sh ould be consid ered to d isting uish betw een th em :
I n ch ild ren und er 3 years, streptococcal ph aryng itis is rare and ph aryng itis is
alm ost exclusiv ely v iral.
I n ch ild ren from 3 to 1 4 years, th e presence of at least 3 of th e 4 follow ing features
[absence of coug h , fev er abov e 3 8 °C , at least one enlarg ed and tend er anterior
cerv ical lym ph nod e, presence of an exud ate] fav ours streptococcal ph aryng itis.
C onv ersely, presence of coug h , runny nose, conjunctiv itis or enlarg ed posterior
cerv ical lym ph nod es fav ours v iral ph aryng itis.
I n patients ov er 1 4 years, th e probability of streptococcal ph aryng itis is low .
I nfectious m ononucleosis (I M ) d ue to th e E pstein-B arr v irus sh ould be suspected in
ad olescents and young ad ults w ith extrem e fatig ue, g eneralized ad enopath y and
often splenom eg aly.
E ryth em atous or exud ativ e ph aryng itis m ay also be associated w ith g onococcal or
prim ary H I V infection. I n th ese cases, th e d iag nosis is m ainly prom pted by th e
patient's h istory.
• Pseudomembranous pharyngitis ( red tonsils/ ph arynx cov ered w ith an ad h erent
g rayish w h ite false m em brane) : see diphtheria, pag e 5 5 .
L ess com m on form s:
• Vesicular pharyngitis (clusters of tiny blisters on th e tonsils): alw ays v iral (coxsackie
v irus or prim ary h erpetic infection).
• Ulcero-necrotic pharyngitis: h ard and painless syph ilitic ch ancre of th e tonsil;
tonsillar ulcer soft on palpation in a patient w ith poor oral h yg iene and
m alod orous breath (V incent tonsillitis).
– L ocal com plications:
P eritonsillar abcess: fev er, intense pain, h oarse v oice, trism us (lim itation of m outh
opening ), unilateral d ev iation of th e uv ula.
53
