Recent Changes

Clinical aspect
Therapies
Conclusion
References
Compiled critical review of the case study

CONCLUSION
The location of the pharynx makes it an easy target for infection entering via the nose and mouth by aerosols from an already infected person or by eating food contaminated with the etiological agent. Though viruses are the main infectious agents of the pharynx, bacterial agents also account for a lower percentage. Many features like epidemiological factors such as; the season of the year and age of the patient, clinical factors and usefulness together with the availability of treatment must also be taken into perspective for diagnostic purposes.
The 6 year old boys’ medical history indicated the absence of previous health problems thus, this was just an opportunistic bacterial infection. The patients’ age was considered, the season in which the disease occurred, the rapid onset of the disease, as well as the common diseases in children of his age group and they all were pointers suggesting acute pharyngitis. Though numerous diseases had very similar symptoms, the sore throat decision rule with defining signs/symptoms i.e. presence of throat exudates, enlarged sub-mandibular glands, fever, and absence of runny nose and cough are classic symptoms/signs of acute pharyngitis caused by group A β-hemolytic streptococcus. The infectious agent can further be confirmed using either a rapid strep test or throat culture or both.
GABHS usually left untreated can be good opportunity for complications to arise e.g. Kidney damage. Thus, it is highly advisable to treat all cases of GABHS related acute pharyngitis.
The treatment plan is most likely to include an analgesic for pain relief and oral Penicillin/its derivatives e.g. amoxicillin as the patient is still young. Amoxicillin is easily absorbed and is thus most likely to be prescribed for treatment of acute pharyngitis in comparison to other treatments. Misuse of antibiotics should also be taken into consideration so as to avoid resistance.
GABHS vaccines are also being developed. An approach to this has been to put together small amino-terminal M-protein peptides in order to produce vaccines which are multivalent and would exhibit opsonic antibodies against GAS serotypes.

{Early diagnosis of streptococcal pharyngotonsillitis by latex particle agglutination test.pdf}
{Acute sore throat.pdf}
{Diagnosis and Management of Pharyngitis in a paediatric population.pdf}
{Differences Among International Pharyngitis.pdf}
{Does Culture Confirmation of High-sensitivity Rapid Streptococcal Tests make sense.pdf}
{Diagnosis of Streptococcal Pharyngitis by Detection of strep in oral cavity specimens.pdf}
{Differences between Belgian and Brazilian Group A.pdf}
{Early diagnosis of streptococcal pharyngotonsillitis by latex particle agglutination test.pdf}
{Clinical and laboratory methods for diagnosis of sore throat.pdf}
{Acute sore throat.pdf}
{Diagnosis and Management of Pharyngitis in a paediatric population.pdf}
List of some articles relating to Acute Pharyngitis avaliable at http://www.ncbi.nlm.nih.gov/pubmed/
Atlas, S. J., McDermott, S. M., Mannone, C. and Barry, M. J. (2005) ‘Brief report: The role of point of care testing for patients with Acute Pharyngitis.’ J Gen Intern Med., 20:759-761.

N. Igboanugo {http://t2.gstatic.com/images?q=tbn:ANd9GcTrKfIdfL81tz06w6MAeYgHwEuIO9Hzbh47QgjtTPoJYF1YVLU5jw} external image images?q=tbn:ANd9GcTrKfIdfL81tz06w6MAeYgHwEuIO9Hzbh47QgjtTPoJYF1YVLU5jw
ID: 000486591
CLINICAL ASPECT OF ACUTE PHARYNGITIS

N. Igboanugo {http://t2.gstatic.com/images?q=tbn:ANd9GcTrKfIdfL81tz06w6MAeYgHwEuIO9Hzbh47QgjtTPoJYF1YVLU5jw} external image images?q=tbn:ANd9GcTrKfIdfL81tz06w6MAeYgHwEuIO9Hzbh47QgjtTPoJYF1YVLU5jw
ID: 000486591
CLINICAL ASPECT OF ACUTE PHARYNGITIS
· Presence of classic signs and also symptoms of S. pyogenes pharyngitis which are; tonsillar exudates, fever, cervical lymphadenopathy with absence of cough.
Chamberlain (2010) stated that clinical and epidemiological factors must be looked at for appropriate diagnosis. Table 1 below shows the clinical and epidemiological factors to be considered as they are suggest bacterial causative agent if present in a patient. Almost all these factors are signs and symptoms as well as epidemiological factors in the 6 year old boy and thus, suggest bacterial etiology i.e. S pyogenes as the infectious agent.
of Pharyngitis
Epidemiologic Epidemiologic findings suggestive
Patient aged 5–15 years
Presentation in winter or early spring
Harari, B. L., Darenberg, J., Neal S., Siljander, T., Strakova, L., Tanna, A., Ekelund, C. R. K., Koliou, M., Tassios, P.T., Van der Linden, M., Straut, M., Vuopio-Varkila, J., Bouvet, A., Efstratiou, A., Schale´n, C., Henriques-Normark, B., the Strep-EURO study group and Jasir, A. (2009) ‘Clinical and microbiological characteristics of severe Streptococcus pyogenes Disease in Europe.’ Journal of clinical microbiology, 47(4), 1155–1165.
Kim, S. (2009) ‘The evaluation of SD bioline Strep A rapid antigen test in Acute Pharyngitis in paediatric Clinics.’ Korean J Lab Med., 29:320-3.

Case study
Topic allocation
Introduction
Infectious agent
Pathogenicity

INTRODUCTION
Acute pharyngitis is the sudden inflammation of the pharynx which may due to viral(mostly) or bacterial(less likely) infection. This infection is in the upper respiratory tract and is always associated with a rapid onset of a sore throat, pain and difficulty in swallowing, enlarged and tender lymph nodes in the neck, fever and enlargement of the tonsils. It has been known to be one of the 5 most common reasons patients visit a primary care physicians in UK.

CRITICAL REVIEW OF THE CASE STUDY ON ACUTE PHARYNGITIS INTRODUCTION
likely) infection. ThisThis infection is
INFECTIOUS AGENTS OF ACUTE PHARYNGITIS
The symptoms described in the case study are appear to describe acute pharyngitis, which is the painful inflammation of the pharynx and surrounding lymphoid tissue, this is because the boys symptoms seem relatively severe and long lasting (36 h). Most acute infections (40%-80%) are cause by viruses. Other causes are bacterial, fungal (although not generally noted as a routinely causative agent) and irritants such as chemicals and pollutants. The following shows the range of different infectious agents that are causatives of acute pharyngitis;
Immune system avoidance
For GAS to cause pharyngitis and start the colonization of the oropharynx, the host innate immune response must be overcome for a periods of time (Ashbaugh et al., 2000; Virtaneva et al., 2005). GAS has modified several mechanisms for escaping the host innate immune response as observed in M protein and hyaluronic acid capsule (Cunningham, 2000). There are other immune proteins which add to GAS pharyngitis such as streptococcal inhibitor of complement (Sic), and secreted DNases . ScpA is a cell surface serine protease that specifically cleaves C5a, thereby decreasing C5apolymorphonuclear (PMN) leucocyte binding and subsequent PMN recruitment (Brown et al., 2005). Sic is a protein secreted to produce protean effects on host immunity at the back of pharynx. In the course of pharyngitis, the gene that encodes Sic is quickly upregulated (Virtaneva et al., 2005). In addition to preventing the complement membrane attack complex, Sic gets involved with pharyngeal immune defence function such as lysozyme, b-defensins, and the cathelicidin LL-37. Due to the interaction of Sic with proteins of the immune system, the bactericidal activity against GAS is strongly reduced.
EPIDEMIOLOGY
PharyngitisEPIDEMIOLOGYPharyngitis mainly affects
The peak occurrence of bacterial and viral Pharyngitis occurs in the school-aged child aged 4-7 years. Pharyngitis, especially GAS infection, is rare in children younger than 3 years. Mycoplasma pneumoniae, Chlamydia pneumoniae and Arcanobacterium haemolyticus are other bacterial that causes Pharyngitis but these are rare. Antibiotics covering atypical pathogens should not routinely be used to treat Pharyngitis (Twefik T. L., 2005)
If a patient is presented with rhinorrhea, cough and hoarseness, doctors will usually test that patient for Group A Streptococcus. It has been shown that it is almost impossible to differentiate between Group A Streptococcus and Pharyngitis caused by viral infection. Rhinovirus and adenovirus are the most common etiological agents and each account for 6-20% of all cases of Pharyngitis, both viral and non-viral. A doctor may order a throat culture. Usually temperature checks are performed along with examinations of the throat, ears, nose, neck and lungs. Pharyngitis is common worldwide and is usually a disorder that affects children. Pharyngitis results in over 15 million hospital visits per year in the United State alone. Acute pharyngitis is the most common cause of a sore throat and is diagnosed in more than 1.9 million people a year in the United States (Marx, John 2010).
Chamberlain (2010) stated that clinical and epidemiological factors must be looked at for appropriate diagnosis. Table 1 below shows the clinical and epidemiological factors to be considered as they are suggest bacterial causative agent if present in a patient. Almost all these factors are signs and symptoms as well as epidemiological factors in the 6 year old boy and thus, suggest bacterial etiology i.e. S pyogenes as the infectious agent.
TABLE 1: Clinical and Epidemiologic Findings Useful in the Diagnosis of Pharyngitis
the etiologic agent| agent
Patient aged 5–15 years
Presentation in winter or early spring
Source: http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/uriphyn.htm
When commenting on epidemiological features, Bisno et al (2002) further contended that the when age of a patient falls between 5-15 years, no child abuse or travel, GABHS should be highly suspected as the causative agent. The patient fits this description and it can thus be said that he has acute pharyngitis caused by GABHS.
this diagnosis:
Rapid
1. Rapid strep test
2. Throat culture (Kim, 2009)
1. Rapid strep test.
Amantadine or neuraminidase inhibitors are used to treat Influenza A pharyngitis if the patient is presented immediately after the start of symptoms. Antiretroviral therapy maybe used for HIV acute retroviral syndrome.
Fluids, gargling with warm and salty water, nonsteroidal anti-inflammatory drugs and rest of voice are some symptomatic relief. Gargling with Chamomile, Blackberry, sage may also help.
CONCLUSION
The location of the pharynx makes it an easy target for infection entering via the nose and mouth by aerosols from an already infected person or by eating food contaminated with the etiological agent. Though viruses are the main infectious agents of the pharynx, bacterial agents also account for a lower percentage. Many features like epidemiological factors such as; the season of the year and age of the patient, clinical factors and usefulness together with the availability of treatment must also be taken into perspective for diagnostic purposes.
The 6 year old boys’ medical history indicated the absence of previous health problems thus, this was just an opportunistic bacterial infection. The patients’ age was considered, the season in which the disease occurred, the rapid onset of the disease, as well as the common diseases in children of his age group and they all were pointers suggesting acute pharyngitis. Though numerous diseases had very similar symptoms, the sore throat decision rule with defining signs/symptoms i.e. presence of throat exudates, enlarged sub-mandibular glands, fever, and absence of runny nose and cough are classic symptoms/signs of acute pharyngitis caused by group A β-hemolytic streptococcus. The infectious agent can further be confirmed using either a rapid strep test or throat culture or both.

CRITICAL REVIEW OF THE CASE STUDY ON ACUTE PHARYNGITIS INTRODUCTION
Acute pharyngitis is the sudden inflammation of the pharynx which may due to viral(mostly) or bacterial(less likely) infection. This infection is in the upper respiratory tract and is always associated with a rapid onset of a sore throat, pain and difficulty in swallowing, enlarged and tender lymph nodes in the neck, fever and enlargement of the tonsils. It has been known to be one of the 5 most common reasons patients visit a primary care physicians in UK.
INFECTIOUS AGENTS OF ACUTE PHARYNGITIS
The symptoms described in the case study are appear to describe acute pharyngitis, which is the painful inflammation of the pharynx and surrounding lymphoid tissue, this is because the boys symptoms seem relatively severe and long lasting (36 h). Most acute infections (40%-80%) are cause by viruses. Other causes are bacterial, fungal (although not generally noted as a routinely causative agent) and irritants such as chemicals and pollutants. The following shows the range of different infectious agents that are causatives of acute pharyngitis;
Amantadine or neuraminidase inhibitors are used to treat Influenza A pharyngitis if the patient is presented immediately after the start of symptoms. Antiretroviral therapy maybe used for HIV acute retroviral syndrome.
Fluids, gargling with warm and salty water, nonsteroidal anti-inflammatory drugs and rest of voice are some symptomatic relief. Gargling with Chamomile, Blackberry, sage may also help.
CONCLUSION
The location of the pharynx makes it an easy target for infection entering via the nose and mouth by aerosols from an already infected person or by eating food contaminated with the etiological agent. Though viruses are the main infectious agents of the pharynx, bacterial agents also account for a lower percentage. Many features like epidemiological factors such as; the season of the year and age of the patient, clinical factors and usefulness together with the availability of treatment must also be taken into perspective for diagnostic purposes.
The 6 year old boys’ medical history indicated the absence of previous health problems thus, this was just an opportunistic bacterial infection. The patients’ age was considered, the season in which the disease occurred, the rapid onset of the disease, as well as the common diseases in children of his age group and they all were pointers suggesting acute pharyngitis. Though numerous diseases had very similar symptoms, the sore throat decision rule with defining signs/symptoms i.e. presence of throat exudates, enlarged sub-mandibular glands, fever, and absence of runny nose and cough are classic symptoms/signs of acute pharyngitis caused by group A β-hemolytic streptococcus. The infectious agent can further be confirmed using either a rapid strep test or throat culture or both.
The treatment plan is most likely to include an analgesic for pain relief and oral Penicillin/its derivatives e.g. amoxicillin as the patient is still young. Amoxicillin is easily absorbed and is thus most likely to be prescribed for treatment of acute pharyngitis in comparison to other treatments. Misuse of antibiotics should also be taken into consideration so as to avoid resistance.
GABHS vaccines are also being developed. An approach to this has been to put together small amino-terminal M-protein peptides in order to produce vaccines which are multivalent and would exhibit opsonic antibodies against GAS serotypes.
REFERENCES
Ashbaugh, C. D., Moser, T. J., Shearer, M. H., White, M. H., Kennedy, R. C. and Wessel, M. R. (2000) 'Bacterial determinants of persistent throat colonization and the associated immune response in a primate model of human group A streptococcal pharyngeal infection.' Cellular Microbiology, 2(4), 283-292.
Bisno, A. L., Gerber, M. A., Gwaltney, J. M. Jr., Kaplan, E. L. and Schwartz, R. H. (2002) 'Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis' Clinical infectious disease, 35(2), 113-25.

Chamberlain (2010) stated that clinical and epidemiological factors must be looked at for appropriate diagnosis. Table 1 below shows the clinical and epidemiological factors to be considered as they are suggest bacterial causative agent if present in a patient. Almost all these factors are signs and symptoms as well as epidemiological factors in the 6 year old boy and thus, suggest bacterial etiology i.e. S pyogenes as the infectious agent.
TABLE 1: Clinical and Epidemiologic Findings Useful in the Diagnosis of Pharyngitis
etiologic agent|
Patient aged 5–15 years
Presentation in winter or early spring
History of exposure
Sudden onset of signs and symptoms
etiologic agent
Sore throat
Fever
Patchy discrete exudate
Tender, enlarged anterior cervical nodes
etiologic agent
Conjunctivitis
Coryza
A swab is taken from the same places as is taken for the rapid antigen test. The specimen is grown on agar blood plates. If GABHS is the etiologic agents, there would be b-hemolytic colonies which are catalase-negative, are gram-positive cocci and also exhibit sensitivity to Bacitracin (Chamberlain, 2010). This test is more sensitive than the rapid antigen test. Though the rapid test is readily available in the Doctors’ office and takes 5 to 10 minutes to perform, the throat culture takes 48 hours to complete thus, leading to the use of the rapid antigen tests more often (Chamberlain, 2010).
It follows that, if the rapid antigen detection test is positive, the throat culture is not required and thus treatment should commence with antibiotics e.g. penicillin. However, if rapid antigen detection test result is negative, a throat culture needs to be carried out (Chamberlain, 2010; Kim, 2009).
THERAPIES
Patients with GAS pharyngitis, empirical treatment should be done immediately to prevent complications, to reduce the infection and transmissibility, and to induce clinical improvement of symptoms. Patients with a higher level of suspicion of GAS pharyngitis but delayedculture results can also be given empirical antibiotics. Alternatively antibiotics can be withheld until the culture is positive for S pyogenes. Delaying the treatment for GAS doesn't have any effect on rheumatic heart disease or the strain of S pyogenes. The latter will reduce the inappropriate antibiotic usage and control the antibiotic resistance.
Selecting antibiotic primarily depend on the way it is to be administered, its effect, cost and condition that is not limited the antibiotic. Penicillin V or amoxicillin is used for around ten days. Intramuscular penicillin G benzathine may be administreted in patients who are unable to complete the ten days period. Macrolides like erythromycin, azithromycin are alternatively used in penicillin allergic patients. Absence of penicillin-resistant GAS compels a cheaper alternative than latest antibiotics which are expensive. Penicillin is not able to prevent nasopharyngeal carriage in patients with frequent GAS pharyngitis .
Amoxicillin/clavulanate or rifampin may be used in such patients. Antibiotics should not be used in patients with negative throat RADT/cultures.
Pharyngitis caused by anaerobic bacteria may respond to penicillins or clindamycin.Yersinia pharyngitis is treated with latest cephalosporin. Mycoplasma pharyngitis is treated by doxycycline or macrolides. Symptomatic oropharyngeal in immunodeficient patients are treated by acyclovir ten days.
Amantadine or neuraminidase inhibitors are used to treat Influenza A pharyngitis if the patient is presented immediately after the start of symptoms. Antiretroviral therapy maybe used for HIV acute retroviral syndrome.
Fluids, gargling with warm and salty water, nonsteroidal anti-inflammatory drugs and rest of voice are some symptomatic relief. Gargling with Chamomile, Blackberry, sage may also help.
CONCLUSION
diagnostic purposes.
The
The 6 year or both.
GABHS usually left untreated can be good opportunity for complications to arise e.g. Kidney damage. Thus, it is highly advisable to treat all cases of GABHS related acute pharyngitis.
avoid resistance.
GABHS
GABHS vaccines are GAS serotypes.
REFERENCES
Ashbaugh,
REFERENCES
Ashbaugh, C. D., 2(4), 283-292.
Bisno,
Bisno, A. L., 35(2), 113-25.
Boccazzi,
Boccazzi, A., Tonelli, 16(3), 287-9.
Chamberlain,
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Edwards,
Edwards, A.M., Manetti, 68(6), 1378-1394.
Gehanno,
Gehanno, P., Portier, 42(3), 284-7.
Guilherme,
Guilherme, L., Kalil, 39(1), 31-9.
Fox,
Fox, J. W., Microbiology, 2593-2594.
Harari,
Harari, B. L., 47(4), 1155–1165.
Herwald,
Herwald, H., Cramer, 116, 367–379.
John,
John, M. (2010) Mosby Elsevier.
Kim,
Kim, S. (2009) Med., 29:320-3.
Pfoh,
Pfoh, E., Wessels, 121(2), 229-34.
Shelburne,
Shelburne, S.A., Sumby, 102: 16037-16042.
Sumby,
Sumby, P., Tart, 431: 255-267.
Tewfik, T. L. and Al Garni, M. (2005) 'Tonsillopharyngitis: Clinical highlights.' J Otolaryngology,34(1), S45-9.
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Walker,
Walker, M. J. (37)13, 308-313.
Zahner, D., and Scott, J. R. (2007) 'SipA is required for pilus formation in Streptococcus pyogenes serotype M3.' J Bacteriol, 190: 527-535.