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URTI Pharangitis

URTI Pharangitis. Mohammed El-Khateeb MSVL-4 Nov 26 th 2013. OVERVIEW. URTI: WHY IS THIS IMPORTANT?. The respiratory system is the most commonly infected system. Health care providers will see more respiratory infections than any other type.

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URTI Pharangitis

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  1. URTIPharangitis Mohammed El-Khateeb MSVL-4 Nov 26th 2013

  2. OVERVIEW

  3. URTI: WHY IS THIS IMPORTANT? • The respiratory system is the most commonly infected system. • Health care providers will see more respiratory infections than any other type.

  4. Geography of the respiratory system (and sites of infection)

  5. …THE RESPIRATORY SYSTEM A major portal of entry for infectious organisms • The upper respiratory tract: • Mouth, nose, epiglottis, Nasal cavity, sinuses, pharynx, and larynx • Infections are fairly common. • Usually nothing more than an irritation • The lower respiratory tract: • Lungs and bronchi • Infections are more dangerous. • Can be very difficult to treat

  6. ANATOMY OF THE RESPIRATORY SYSTEM • The most accessible system in the body, continuously exposed to potential pathogens. • Breathing brings in clouds of potentially infectious pathogens. • The body has a variety of host defense mechanisms. • Innate immune response The cells and mechanisms that defend the host from infection by other organisms, in a non-specific manner • Adaptive immune It is adaptive immunity because the body's immune system prepares itself for future challenges.

  7. Protective structures of the • respiratory system • Ventilatory flow • Involuntary responses such as coughing, • sneezing and swallowing • Mucous membranes • Hairs; ciliated epithelia • Lymphoid tissues (tonsils) • “Mucociliary escalator” keeps microbes • out of lower respiratory tract • Alveolar macrophages; IgA

  8. The Respiratory Tract and Its Defenses • Normal Flora: • Moraxella, • nonhemolytic and a-strep, • Coryenbacterium, • Diphtheroids, • Candida albicans, • Others

  9. Pharnygitis Definition: Inflammation of the mucous membranes and submucosal structures of the oropharynx but not tonsils Sore Throate

  10. ETIOLOGY • 30%-65%: idiopathic • 30%-60%: viral • 5%-10%: bacterial • Group A beta-hemolytic: most common bacterial pathogen • 15%-36%: pediatric cases • 5%-10% : adult pharyngitis • Disease of children

  11. Etiology • Strep.A • Mycoplasma • Strep.G • Strep.C • Corynebacterium diphteriae • Toxoplasmosis • Gonorrhea • Tularemia • Rhinovirus • Coronavirus • Adenovirus • CMV • EBV • HSV • Enterovirus • HIV

  12. Pharyngitis • Pharyngeal mucosa exhibits an inflammatory response to many other agents other than viruses • Opportunistic bacteria • Fungi • Environmental pollutants • Neoplasm • Granulomatous disease • Chemical and physical irritants

  13. Incidence • Sore throatis estimated to account for 10% of all general practice consultations • Asymptomatic carriage of streptococcus • Is common with rates of 6 - 40% • Carriers have low infectivity and are not at risk of developing complications such as rheumatic fever

  14. Pharyngitis • Inflammation of the throat • Pain and swelling, reddened mucosa, swollen tonsils, sometime white packets of inflammatory products • Mucous membranes may swell, affecting speech and swallowing • Often results in foul-smelling breath • Incubation period: 2-5 days

  15. Clinical manifestation (Viral) • Sore throat • Pain on swallowing • Fever • Hoarseness if laryngeal involvement • Gradual onset • Rhinorrhea • Cough • Diarrhea • Headache • Malaise

  16. Signs • Redness of the pharynx and tonsils • Presence of exudate • Enlarged tonsils • Swollen tender neck glands. • Note that a streptococcal sore throat is impossible to diagnose on clinical grounds alone.

  17. Physical Examination • Full head and neck exam • General – respiratory distress, toxic • Face – mouth breathing • Nose – rhinorrhea • Neck – lymph nodes, thyroid, • Mucosal edema, tonsillar swelling, exudates, discrete lesions, deviation of the uvula or tonsillar pillars, bulges in the posterior pharyngeal wall • Laryngoscopy • Nasal endoscopy - sinusitis

  18. PHARYNGITIS • Treatment • VIRAL – Supportive care only – Analgesics, Antipyretics, Fluids • No strong evidence supporting use of oral or intramuscular corticosteroids for pain relief → few studies show transient relief within first 12–24 hrs after administration • EBV – infectious mononucleosis • activity restrictions – mortality in these pts most commonly associated with abdominal trauma and splenic rupture

  19. Complications

  20. Sinusitis • Commonly called a sinus infection • Most commonly caused by allergy • Can also be caused by infections or structural problems • Generally follows a bout with the common cold • Symptoms: nasal congestion, pressure above the nose or in the forehead, feeling of headache or toothache • Facial swelling and tenderness common • Discharge appears opaque with a green or yellow color in case of bacterial infection • Discharge caused by allergy is clear and may be accompanied by itchy, watery eyes

  21. Acute Otitis Media (Ear Infection) • Also a common sequel of rhinitis • Viral infections of the upper respiratory tract lead to inflammation of the Eustachian tubes and buildup of fluid in the middle ear- can lead to bacterial multiplication in the fluids • Bacteria can migrate along the eustachian tube from the upper respiratory tract, multiply rapidly, leads to pu production and continued fluid secretion (effusion) • Chronic otitis media: when fluid remains in the middle ear for indefinite periods of time (may be caused by biofilm bacteria) • Symptoms: sensation of fullness or pain in the ear, loss of hearing • Untreated or severe infections can lead to eardrum rupture

  22. Figure 21.2

  23. Infectious causes of pharyngitis

  24. Viruses • Most common agents in pharyngitis are the rhinovirus and coronavirus • Both single stranded, + sense RNA picornaviruses • Grow best at 33 degrees Celsius • Approximates the temperature of the nasopharynx • Disease is self-limited • Clinical signs and symptoms may be identical to bacterial pharyngitis • Evaluation for Group A streptococcus is advisable

  25. Viruses • Major cause of acute respiratory disease • Rhinovirus &Coronaviruses • Respiratory syncicial virus • Parainfluenza viruses • Respiratory syncicial virus • Herpes Group • HIV

  26. VIRAL INFECTIONS OF THE UPPER RESPIRATORY TRACT (URT) • RHINOVIRUS INFECTION -There are several hundred serotypes of rhinovirus. • Fewer than half have been characterized. • 50% that have are all picornaviruses. • Extremely small, non-enveloped, single-stranded RNA viruses • Optimum temperature for picornavirus growth is 33˚C. • The temperature in the nasopharynx

  27. …VIRAL INFECTIONS OF THE UPPER RESPIRATORY TRACT • PARAINFLUENZA: There are four types of parainfluenza virus. • All belong to the paramyxovirus group. • Single-stranded enveloped RNA viruses • Contain hemagglutinin and neuraminidase • Transmission and pathology similar to influenza virus, but there are differences. • Parainfluenzavirus replicates in the cytoplasm. • Influenza virus replicates in the nucleus.

  28. ..PARAINFLUENZA • Parainfluenza is genetically more stable than influenza. • Very little mutation • Little antigenic drift • No antigenic shift • Parainfluenzais a serious problem in infants and small children. • Only a transitory immunity to reinfection • Infection becomes milder as the child ages.

  29. Respiratory Syncytial Virus Infection • Produces giant multinucleated cells (synctia) in the respiratory tract • Most prevalent cause of respiratory infection in the newborn age group • First symptoms: fever that lasts approximately 3 days, rhinitis, pharyngitis, and otitis • More serious infections give rise to symptoms of croup: coughing, wheezing, dyspnea, rales

  30. Epstein-Barr Virus (EBV) • Etiologic agent of infectious mononucleosis (IM) • Herpes virus 4 • Double stranded DNA virus • Selectively infects B-lymphocytes

  31. Ebstein-Barr Virus (EBV) • Early infections in life are mostly asymptomatic • Clinical disease is seen in those with delayed exposure (young adults) • Defined by clinical triad • Fever, lymphadenopathy, and pharyngitis combined with +heterophil antibodies and atypical lymphocytes

  32. Ebstein-Barr Virus (EBV) • Other clinical findings • Splenomegaly – 50% • Hepatomegaly – 10% • Rash – 5%

  33. Ebstein-Barr Virus (EBV) • Pharyngitis • White membrane covering one or both tonsils • Petechial rash involving oral and palatal mucosa

  34. Ebstein-Barr Virus (EBV) • Diagnosis • By Clinical presentation • CBC with differential (atypical lymphocytes –T lymphocytes) • Detection of heterophil antibodies (Monospot test) • IgM titers

  35. Treatment • Supportive management • Rest • Avoidance of contact sports (?->splenic rupture?) • Glucocorticoids (severe cases)

  36. Ebstein-Barr Virus (EBV) • Complications • Autoimmune hemolytic anemia • Cranial nerve palsies • Encephalitis • Hepatitis • Pericarditis • Airway obstruction

  37. Cytomegalovirus (CMV) • Herpes virus 5 • Ubiquitous • 50% of adults seropositive • 10-15% of children seropositive by age 5 years • Etiology of 2/3 of heterophil-negative mononucleosis

  38. Cytomegalovirus (CMV) • Clinical manifestation • Fever and malaise • Pharyngitis and lymphadenopathy less common • Esophagitis in HIV infected patients

  39. Cytomegalovirus (CMV) • Diagnosis • 4-fold rise in antibody titers to CMV

  40. Herpes Simplex Virus (HSV) • Herpes (Greek word herpein, “to creep”) • Two antigenic types (HSV-1, HSV-2) • Both infect the upper aerodigestive tract • Transmission is by direct contact with mucous or saliva

  41. Herpes Simplex Virus (HSV) • Clinical manifestations • Depends on • Anatomic site • Age • Immune status of the host • First episode (primary infection) • More systemic signs and symptoms • Both mucosal and extramucosal sites involved • Longer duration of symptoms

  42. Herpes Simplex Virus (HSV) • Clinical manifestations: • Gingivostomatitis and pharyngitis – most common in first episode • Usually in children and young adults • Fever, malaise, myalgias, anorexia, irritability

  43. Herpes Simplex Virus (HSV) • Physical exam • Cervical lymphadenopathy • Pharynx – exudative ulcerative lesions • Grouped or single vesicles on an erythematous base • Buccal mucosa • Hard and soft palate

  44. Herpes Simplex Virus (HSV) • Clinical manifestations • Acute illness evolves over 7-10 days • Rapid regression of symptoms • Resolution of lesions

  45. Herpes Simplex Virus (HSV) • Immunocompromised patient • Persistent ulcerative lesions are common in patients with AIDS • Lesions more friable and painful • Aggressive treatment with IV acyclovir

  46. Herpes Simplex Virus (HSV) • Diagnosis • Usually clinical • Isolation of HSV • Culture from scrapings of lesions • Results in 48 hours

  47. Herpes Simplex Virus (HSV) • Treatment • Acyclovir, 400 mg PO 5X/day X 10days • Valacyclovir, 1000 mg PO BID X 10 days • Recurrent disease • Acyclovir 400 mg PO 5X/day for 5 days • Duration reduced from 12.5 to 8.1 days • Acyclovir 400 mg po bid every day • Recurrence reduced 36% to 19%

  48. Human Immunodeficiency Virus (HIV) • Pharyngitis • Usually opportunistic infection • HSV • CMV • Candida • Viral particles have been detected in lymphoepithelial tissues of the pharynx

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