111 年第一次

醫學（四） 3-5
Presenter: clerk 2 蘇雋淋
Date: 2022/03/11
 Pharyngitis
• inflammation of the pharynx, including erythema,
edema, exudates, ulcers or vesicles
• Risk factor:
– Environmental exposure: tobacco smoke, air pollutants,
and allergens
– Contact with caustic substances, hot food, and liquids
– infectious agents.
 Etiology
Viral : More common
• Spread : close contact
• Peak during winter and spring
• EBV or cytomegalovirus related mononucleosis ->
adolescents and young adults
 Viral Pharyngitis
AGENT TRAITS ESTIMATED PROPORTION OF ALL
PHARYNGITIS (%)
VIRAL
Rhinoviruses (>100 types) 20
Coronaviruses (>4 types)
URI >5
Adenoviruses (types 3, 4, 7, 14, 21) Pharyngoconjunctival fever, acute 5
respiratory disease
Herpes simplex viruses (types 1, 2) Gingivostomatitis, anterior pharynx 4
Parainfluenza viruses (types 1-4) URI, croup 2
Influenza viruses (types A and B) Influenza 2
Epstein-Barr virus Unknown
Cytomegalovirus
Mononucleosis Unknown
Coxsackie virus Herpangina, hand, foot and mouth Unknown
disease, posterior pharynx
 Etiology
Bacterial : Group A streptococcus
• Streptococcal pharyngitis
– Young school-age
– Occurs throughout the year in temperate climates
– Spread easily
 Bacterial Pharyngitis
AGENT TRAITS ESTIMATED PROPORTION OF ALL
PHARYNGITIS (%)
BACTERIAL
Group A streptococcus Pharyngitis, tonsillitis, scarlet fever 15-30
( Streptococcus pyogenes )
Group C and G streptococcus adolescents and adults 1-5

Arcanobacterium haemolyticum adolescents and adults, Scarlet fever- 0.5-3

like syndrome
Fusobacterium necrophorum adolescents and adult, Lemierre Unknown
syndrome
Mycoplasma pneumoniae Pharyngitis, pneumonia Unknown
Other (e.g., Neisseria gonorrhoeae, Pharyngitis, laryngitis, tularemia <5
Corynebacterium diphtheriae,
Francisella tularensis)
 Clinical Manifestations
• Cough, sore throat, dysphagia, and fever
• ↑ involve tonsils -> tonsillitis/tonsillopharyngitis
• Streptococcal pharyngitis
– Incubation period: 2-5 days
– Rapid onset, soar throat + moderate to high fever
– Headache, nausea, vomiting, and abdominal pain
 Streptococcal pharyngitis
• Pharynx and uvula: red and swollen
• Tonsils: enlarged with exudate ± blood-tinged
• Soft palate and posterior pharynx : petechiae or
doughnut lesions
• Strawberry Tongue: white -> red
 Scarlet fever
• streptococcal pyrogenic exotoxin A, B, or C
• fine red, papular (sandpaper) rash
– Face -> generalized
– Circumoral pallor
– Pastia’s lines: sometimes petechial or slightly hemorrhagic
– Fades in a few days -> peels like a mild sunburn
 Laboratory Evaluation
• Rapid streptococcal antigen test :
– specificity of 95–99%, sensitivity varies
– (-) -> throat culture or polymerase chain reaction (PCR)
– (+) : 20% are chronic carrier
• White blood cell count in infectious mononucleosis :
↑ atypical lymphocytes.
 Treatment
• Most resolve without treatment over a few days
• Early antimicrobial therapy
– Accelerates clinical recovery by 24–48 hours
– Prevent acute rheumatic fever : start within 9 days of
treatment -> 100% prevention
 Enterovirus
• Nonenveloped, single-stranded, positive-sense
• Picornaviridae (“small RNA virus”) family
• Old subgroup : polioviruses, coxsackieviruses, and
echoviruses
• Classified by gene : human enteroviruses A-D
 Pathophysiology
Oral or respiratory acquisition -> Replication in pharynx ->
Transmission Lymphoid tissue (tonsils, Peyer patches, and regional lymph
nodes)
• Primary, transient viremia -> subclinical, no symptoms
Minor viremia • Reticuloendothelial system (liver, spleen, bone marrow, and
distant lymph nodes)

• Secondary, sustained viremia

Major viremia • CNS : Encephalitis
• Heart : myocarditis
• Liver, lung, pancreas, kidney, muscle and skin
 Nonspecific Febrile Illness
• Most common symptomatic manifestations
• Fever of 38.5-40°C : 3 days, occasionally biphasic
• Skin : macular, maculopapular, urticarial, vesicular,
and petechial eruptions
• Malaise, irritability, sore throat and GI symptoms
 Hand-Foot-and-Mouth Disease
• Coxsackievirus A16, enterovirus A71; coxsackie A
viruses 5, 6, 7, 9, and 10; coxsackie B viruses 2 and 5
• Mild illness ± low-grade fever
• Mouth :
– scattered painful vesicle over oral cavity and lips
– ulcerate, leaving 4-8 mm shallow lesions with surrounding
erythema
 Hand-Foot-and-Mouth Disease
• Skin lesions:
– Hand > feet, dorsal surface, buttocks and groin
– Maculopapular, vesicular, and/or pustular lesions
– Painful, 3-7mm, resolve in 1 week
– May complicate preexisting atopic dermatitis
Hand-Foot-and-Mouth Disease
 Herpangina
• Coxsackie A viruses, Enterovirus A71
• Sudden onset of fever (normal to 41°C ), higher
in younger patients, last 1-4 days
• Vesicles and ulcers -> Sore throat, Dysphagia
– Oral cavity and posterior pharyngeal wall
– 1mm -> 3-4 mm + erythematous rings over 2-3 days
– No, of lesions : 5 (1 to >15)
 Herpangina
• Most cases are mild, last 3-7 days
• Complication:
– Dehydration due to decreased oral intake
– Meningitis or more severe illness.
 Myocarditis and Pericarditis
• 25–35% of cases with myocarditis/pericarditis
• Coxsackie B viruses, coxsackie A viruses and
echoviruses
• Dominant feature / 1 manifestation of disseminated
disease
• Upper respiratory symptoms -> fatigue, dyspnea,
chest pain, congestive heart failure, and
dysrhythmias
 Myocarditis and Pericarditis
• Chest x ray : cardiac enlargement
• Cardiac Echo : ventricular dilation, reduced
contractility, ± pericardial effusion
• ECG : ST segment, T wave ± rhythm abnormalities
• Cardiac enzyme : elevated
• Mortality : 0–4%, most recover completely
 Encephalitis
• ≥10–20% cases of encephalitis
• Most common : Enterovirus A71
• Nonspecific symptoms -> confusion, weakness,
lethargy, and/or irritability
• Seizure, chorea, ataxia and aphasia may occur
 Encephalitis
• Most cases are meningoencephalitis : (+) Meningeal
signs and CSF studies
• <5 yr of age : mortality ↑
• Deficits have been observed:
– central hypoventilation
– bulbar dysfunction
– neurodevelopmental delay
 Etiology
• Most common : Rhinoviruses
• Others : Respiratory syncytial virus (RSV), coronaviruses,
coxsackieviruses, influenza, parainfluenza, and
adenoviruses
• Infect nasal epithelium -> Host response with mucosal
infiltration by inflammatory cells and release of cytokines
-> most symptoms.
 Clinical Manifestations
• Incubation periods : 1-3 days
• Fever: may occur in infants/young children
• Nasal congestion
• Rhinorrhea : change in the color/consistency ≠
bacterial superinfection or sinusitis
• Sore or scratchy throat
 Laboratory and Imaging Studies
• Nasopharyngeal swab -> polymerase chain
reaction (PCR)
• Evaluation for allergic rhinitis :
– Skin testing
– Specific immunoglobulin E (IgE) testing
– Nasal smear for eosinophils
 Treatment
• Symptomatic therapies
× Antibacterial therapy
× Antihistamines / decongestants for < 6 years
× Cough suppressants and expectorants
× Vitamin C and inhalation of warm, humidified
air, no more benefit than placebo
 Complications
• Otitis media (5%) : most common
• Bacterial sinusitis considered if
– Rhinorrhea or daytime cough > 10–14 days
– High fever > 3 days
– Facial pain or facial swelling
• Exacerbation of asthma -> inappropriate antibiotic treatment
• Lower respiratory tract infections : in immunocompromised
patients
 Reference
• Nelson Textbook of Pediatrics, Chapter 409, 2192-
2196.e1
• Nelson Textbook of Pediatrics, Chapter 277, 1690-
1697.e1
• Nelson Essentials of Pediatrics, Chapter 102, 408-409
Thanks for your attention!