Sore throat:
What is it?
Examples
Common causes?
- Symptom of pain at back of throat
- Acute pharyngitis (inflammation of orthopharynx)
- Tonsillitis
- Acute pharyngitis (inflammation of orthopharynx)
- Viral or bacterial infection
- Less commonly: non-infectious causes
- Rhinovirus, coronavirus, parainfluenza, etc.
- Common cold (25%)
- Influenza (4%)
- Streptococcus pyrogenes (G+) (GABHS - Group A beta-haemolytic Streptococcus)
- Herpes simplex (2%)
- Viral or bacterial infection
Glandular fever:
Usually caused by?
EBV
Symptoms
Cure?
- Epstein-Barr virus (EBV)
- Common herpes virus people have, often with no symptoms
- Fatigue
Symptoms may continue for weeks and fatigue may persist for months - No cure, usually passes without treatment
Glandular fever (infectious mononucleosis):
Triad
Symptoms
- Sore throat, fever and lymphadenopathy
- Fever of 38-39C
- Tonsils enlarged, occasionally meeting in midline
- Pharynx may be erythematous with exudate (tender, red throat with fluid from tonsils)
- Palatal petechiae may be present but not diagnostic of infection mononucleosis
- Usually moderate bradycardia
- Very tired
- Fever of 38-39C
Glandular fever - prescribe:
DO NOT prescribe
Viral disease
Corticosteroids
- DO NOT prescribe amoxicillin or ampicillin - causes a rash for most people with glandular fever
- Antibiotics sometimes needed to treat secondary infections but rare
- May be considered to reduce inflammation but only if persistent
Non-infectious sore throat:
Causes
- Irritation
- Hayfever (rare)
- Adverse drug reactions
Sore throat - complications:
- Otitis media, sinusitis
- Quinsy (Peri-tonsillar abscess)
- Risk of death
- Severe pain, fever, dysphagia, drooling, hot potato voice…
Quinsy (peritonsillar abscess (PTA)):
Consists of?
How many people can develop quinsy from a sore throat?
- Consists of a collection of pus beside tonsil referred to as Peritonsilar space
- Only 1% of people with a sore throat may develop quinsy - most common in teenagers/young adults
Sore throat - prognosis/diagnosis:
- Self limiting
- 3-7 days in most people
- Viral or bacterial - not possible to clinically distinguish type
- Centor or FeverPain (clinical prediction scores)
- Developed to predict bacterial
- Bacterial: whitish spots, swollen uvula and grey furry tongue
Centor criteria:
Developed to predict what?
What are the 4 criteria?
What does the presence of 3/4 signs suggest?
Absence of 3/4 signs suggests?
- Bacterial infection (GABHS) in people with acute sore throat
- Presence of tonsillar exudate
- Presence of tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever
- Absence of cough
- Presence of tonsillar exudate
- Person may have GABHS (40-60%) and may benefit from antibiotics
- Unlikely infection
Non-infectious sore throat - management:
Refer if…
- Breathing difficulty, dehydration (A&E)
- Immunosuppressed e.g. DMARD’s/HIV
- Suspected ADR
Non-infectious sore throat - advice:
- Avoid contact with others
- Usually self-limiting (3-7 days)
- Paracetamol or ibuprofen (BNF dose)
- Adequate fluid intake
- Medicated Lozenges
- Poor evidence for local anaesthetic sprays, non-medicated Lozenges or mouthwashes
Non-infectious sore throat - antibiotic use:
What script is used?
What does the Centor score need to be?
Most common s/e
Who are at risk of complications?
- Delayed Rx
- Centor score 3+
- Marked systemic upset
- Valvular heart disease, diabetic or immunocompromised, rheumatic fever and recurrent GABHS
Non-infectious sore throat - antibiotic use:
Treatment
If allergic to 1st line? What does this treatment increase the risk of and more effects of?
Avoid which treatment?
- Use phenoxymethylpenicillin (5-10 days) - BNF ( 10 days increase chance of cure)
- Erythromycin/clarithromycin for 5 days (reserved - broader spectrum)
- Increased risk of Clostridium difficile
- More adverse effects/DIs - Broad spectrum
Phenoxymethylpenicillin (Penicillin V):
Acid stable or unstable?
Active against which bacteria?
What type of agent is it?
Little penetration into which structures?
Peak serum levels when?
Mainly excreted in which form?
- Acid stable
- G+ cocci e.g. Streptococcus pyrogenes
- 30 mins
- CSF and sinus
- Unchanged
Phenoxymethylpenicillin (Penicillin V) - cautions:
Hypersensitivity reactions
Drug interactions
- Anaphylaxis (0.05%)
- Serum sickness (late reactions 7-10 days) 2%
- Contact dermatitis
- Local reactions
- Anaphylaxis (0.05%)
- Few - probenecid (kidney)
Ringworm:
What is it?
What type of parasite is it?
More common in?
Transmitted by?
- Fungal skin infection also known as tinea
- Dermatophytes
- More common in men
- Direct contact (including animals - Zoonoses)
- Indirect contact
- Direct contact (including animals - Zoonoses)
Ringworm:
Diagnosed from?
How to respond if unsure on diagnosis?
Contagious?
Occurs where?
- Pink, flat-ring shaped rash
- Culture if unsure, non responsive treatment, oral considered
- Common and highly contagious infection
- Most parts of body - mostly scalp, feet and groin
Ringworm:
What do dermatophytes live off?
How tough are fungi spores?
- Keratin
- Fungi spores are tough enough to survive several months on skin, in soil or on household objects
Ringworm - at risk groups:
- Very young/old
- African-Caribbean (scalp ringworm)
- Type 1 diabetics
- Overweight
- Weakened immune system (HIV/AIDS)
- Receiving medical treatment that weakens immune system (chemo or steroid tablets)
- Fungal infection had in past
- Hardening of arteries (atherosclerosis)
- Have poor circulation (specifically venous insufficiency - veins in legs have trouble moving blood to heart)
Ringworm - advice:
- Wash and dry skin daily
- Wash clothes and bed linen
- Don’t share
- Loose fitting clothing
- No need to be excluded from school
Ringworm - treatment - fungal infections:
Mild
Severe
- Topical
- Clotrimazole (4 weeks after healing)
- Miconazole (10 days after healing)
- Topical
- Topical steroids (NOT ALONE)
- If treatment failed - oral antifungals
- Topical steroids (NOT ALONE)
Clotrimazole:
2 mechanisms of action
- Fungistatic (inhibition of sterol synthesis - cell membrane)
- Fungicidal at higher concs. (inhibits calcium and potassium channels)
Clotrimazole:
Available preparations
Profile if systemic
Major s/e
- Lozenges, vaginal tablets, creams, lotions
- Poor profile if systemic - good absorption, rapid metabolism (first pass effect)
- Irritation/burning - 15% of patients
Treatments for tinea - tinea capitas:
- Topical application of ketoconazole and systemic itraconazole or terbinafine
- Tinea corporis - topical clotrimazole, miconazole, terbinafine
