here and there

1. here and there February 27, 2013 Case conference

2. CC: sore throat Justin is a 13-year-old boy who has had sore throat, fever, and swollen glands for two days.

3. Strep vs viral pharyngitis? • Tonsillar exudates LR+: 3.4 • Pharyngeal exudates LR+: 2.1 • + Exposure LR+: 1.9 • Palatine petechiaevery specific Absence of: • tender anterior cervical nodes LR-: 0.6 • tonsillarenlargement (LR-: 0.6) • exudate (LR-: 0.7) Justin is a 13-year-old boy who has had sore throat, fever, and swollen glands for two days.

4. Use the CENTOR SCORE to diagnose and treat GAS pharyngitis. Justin is a 13-year-old boy who has had sore throat, fever, and swollen glands for two days. Exam: T 100.8 exudative tonsils tender anterior cervical nodes no posterior cervical adenopathy. Centor score: 5, 52% likely

5. What would you say? a) It is likely that his symptoms will resolve in a few days without treatment. b) His symptoms will likely last for 5-7 days longer without treatment. c) If he is not treated is likely that he will develop rheumatic heart disease. d) It is important to prevent post strep glomeulonephritis which can lead to chronic kidney failure. Justin is a 13-year-old boy who has had sore throat, fever, and swollen glands for two days. Exam: T 100.8 exudative tonsillitis tender anterior cervical nodes no posterior cervical adenopathy. Centor score: 5, 52% likely You recommend treatment His mother declines antibiotics. “His sore throat is likely to resolve on its own.”

6. a) It is likely that his symptoms will resolve in a few days without treatment - correct b) His symptoms will likely last for 5-7 days longer without treatment. - Reduce duration of sore throat by ~16 hrs, c) It is likely that he will develop rheumatic heart disease if he is not treated. NNT 3000-4000 (developed countries) d) It is important to prevent post strep glomerulonephritis which can lead to chronic kidney failure Unclear if treating the original infection prevents this, studies are too small. >95% recover spontaneously in 3-4 weeks w/o long term sequele Justin is a 13-year-old boy who has had sore throat, fever, and swollen glands for two days. Exam: T 100.8 exudative tonsillitis tender anterior cervical nodes no posterior cervical adenopathy. Centor score: 5, 52% likely His mother does not want to treat him with antibiotics, she says that it is likely to resolve on its own.

7. Treatment is recommended for GAS pharyngitis Should we recommend treatment for anyone? Yes [AAFP, AAP, ACP, CDC ] - Reduced communicability - Reduction in symptom duration - Prevention of complications (Cochrane 2006) • Acute rheumatic fever • Otitis media • Peritonsilar abscesses Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment NNT ~ 95 NNT ~ 80 NNT ~ 60

8. RTC / Warning signs? Suppurative: Bacteremia Cervical lymphadenitis, Endocarditis Mastoiditis Meningitis Otitis media, Peritonsillar/Retropharyngeal abscess Pneumonia Non Suppurative: Poststreptococcalglomerulonephritis Rheumatic fever Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment

9. Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment 10 months later He had recovered after about 1 week, missed two days of school No apparent consequences Now back with: + fever, sore throat, + strep culture Declined treatment

10. What is your differential? Viral URI Septic arthritis SLE Viral arthropathy Rhematic fever Leukemia or lymphoma Infective endocarditis Sickle cell Lyme disease Mononucleosis Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment 10 months later: He had recovered after about 1 week, missed two days of school Recovered without consequences + fever, sore throat, + strep culture Declined treatment ~1 month later: He had recovered Now back with: T: 101, sore throat, arthralgia, tonsilar exudate

11. Acute rheumatic fever Febrile illness 14-21 days after GAS * Migratory arthritis Carditis Chorea Erythema marginatum Swelling over bony prominences, non tender Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment 10 months later: He had recovered after about 1 week, missed two days of school Recovered without consequences + fever, sore throat, + strep culture Declined treatment ~ 1 months later: He had recovered Now back with: T: 101 arthralgias, tonsilar exudate

12. Erythma marginatum occurs in ~5% of rheumatic fever

13. Sydenham’s Chorea20-30% of patients with rheumatic fever http://www.youtube.com/watch?v=vqu5RtDh9sw

14. Subcutaneous nodulespainless over bony prominences

15. Labs or studies? ASO or strep culture CRP, ESR UA EKG +/ - Echo Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment 10 months later: He had recovered after about 1 week, missed two days of school Recovered without consequences + fever, sore throat, + strep culture Declined treatment ~ 1 months later: He had recovered T: 101 arthralgias No murmur No erythema marginatum, chorea, subcutaneous nodules

16. Jones criteria: preceding GAS and 2 major OR 1 major and 2 minor criteria major criteria polyarthritis carditis chorea subcutaneous nodules erythema marginata minor criteria history of acute rheumatic fever (ARF) or rheumatic heart disease (RHD) Fever arthralgias inflammation on blood testing increased erythrocyte sedimentation rate (ESR) increased C-reactive protein prolonged PR interval Justin is a 13-year-old boy who has who has GAS pharyngitis. Mother declines treatment 10 months later: He had recovered after about 1 week, missed two days of school Recovered without consequences + fever, sore throat, + strep culture Declined treatment ~ 1 months later: He had recovered T: 101 arthralgias, cough No murmur labs, + strep culture EKG Echo ???

17. Treatment of chronic strep carriage, rarely Treatment for chronic strep carriage: • Personal history of or close contact with someone who has had: • Acute rheumatic fever • Post-strep glomerulonephritis • Invasive GAS infection • Recurrent GAS pharyngitis • Community outbreak of rheumatic fever • Health care workers • Children at risk of tonsillectomy for repeated pharyngitis

18. Treatment of acute rheumatic fever penicillin and anti inflammatory Treatment of rheumatic fever - Bed rest - Supportive - Anti-strep therapy - Anti-inflammatory 4-6 weeks • Aspirin • Steroids Justin is a 13-year-old boy who has who has GAS pharyngitis. Mother declines treatment 10 months later: + GAS Declined treatment ~ 1 months later: + strep - Rheumatic fever

19. Seondary prevention – prevention of recurrent attacks: long term penicillin Indications for continuous prophylaxis after rheumatic fever Treatment: penicillin 250mg PO bid, IM injections q4 weeks sulfadiazine daily Duration: + heart disease: 10 years or until age 40 whichever is longer No heart disease: 10 years or age 21 whichever is longer Justin is a 13-year-old boy who has GAS pharyngitis. Mother declines treatment 10 months later: + GAS Declined treatment ~ 1 months later: + strep - Rheumatic fever

20. Long term consequences of rheumatic fever: Chorea may last 2-3 yrs Carditis only permanent sequele Mitral stenosis is the main complication, needs to be treated surgically

21. Incidence: Rheumatic fever develops in: • 3% in epidemics of exudative GAS infection • 0.3% in US with sporadic GAS pharyngitis • 50% if history of rheumatic fever • First attack 5-15 yrs • Poor socioeconomic conditions and over crowding Rheumatic heart disease: • 10-20 million new cases per year • the major cause of acquired valvular disease in the developing world

22. Take home points: • Use the CENTOR SCORE to diagnose and treat GAS pharyngitis. • Treatment is recommended for GAS pharyngitis • Treatment of chronic strep carriage, rarely indicated • Treatment of acute rheumatic fever: penicillin and anti inflammatory • Secondary prevention – prevention of recurrent attacks: long term penicillin for at least 10 years