Excerpt from Pharyngitis

Synonyms, Key Words, and Related Terms: infection of pharynx, irritation of pharynx, infection of tonsils, irritation of tonsils, group A beta-hemolytic streptococcal infections, GABHS infections, bacterial pharyngitis, viral pharyngitis, acute rheumatic fever, acute glomerulonephritis, upper respiratory infections, URIs, heart valve damage, Streptococcus pyogenes, rhinovirus, adenovirus, peritonsillar abscess, toxic shock syndrome, airway obstruction, Mycoplasma pneumoniae, Chlamydia pneumoniae, Arcanobacterium haemolyticus, rhinorrhea, gonococcalpharyngitis, coxsackievirus A, coxsackievirus B, herpes simplex, infectious mononucleosis, cytomegalovirus, CMV, odynophagia, tonsillopharyngeal petechiae, palatal petechiae, hand-foot-and-mouth disease, cervical lymphadenopathy, acute lymphoglandular syndrome, hepatosplenomegaly, sandpapery scarlatiniform rash, maculopapular rashes, scarlet fever, meningitis, endocarditis, subdural empyemas, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Epstein-Barr virus, EBV, HIV-1, oral thrush, gastroesophageal reflux disease, GERD, smoking, endotracheal intubation, allergy, postnasal drip

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Background

Pharyngitis is defined as an infection or irritation of the pharynx and/or tonsils. The etiology is usually infectious, with 40-60% of cases being of viral origin and 5-40% of cases being of bacterial origin. Other causes include allergy, trauma, toxins, and neoplasia.

The main ED concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A beta-hemolytic streptococcal (GABHS) infections. GABHS infections can have serious sequelae and represent approximately 15% of all ED pharyngitis visits.

Pathophysiology

With infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response. Other viruses, such as rhinovirus, can cause irritation of pharyngeal mucosa secondary to nasal secretion.

Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases. In addition, M protein fragments of certain serotypes of GABHS are similar to myocardial sarcolemma antigens and are linked to rheumatic fever and subsequent heart valve damage. Acute glomerulonephritis may result from antibody-antigen complex deposition in glomeruli.

Frequency

United States

Children experience more than 5 upper respiratory infections (URIs) per year and an average of one streptococcal infection every 4 years. The occurrence in adults is about one half that rate. The most significant bacterial agent causing pharyngitis in both adults and children is GABHS infection (Streptococcus pyogenes), and the most common viruses are rhinovirus and adenovirus. GABHS is most prevalent in late fall through early spring.

International

The incidence of pharyngitis is higher internationally. Antibiotic resistance may be more prevalent in some countries because of overprescription of antibiotics. It should be noted, however, that there has never been a documented case of GABHS resistant to penicillin anywhere in the world.

Mortality/Morbidity

One in 400 cases of untreated GABHS infections can be expected to result in acute rheumatic fever. This rate is higher in less developed countries and might actually be lower in the Western world.
Other sequelae of streptococcal pharyngitis include acute glomerulonephritis, peritonsillar abscess, and toxic shock syndrome.
Mortality from pharyngitis is rare but may result from one of its complications. For the ED physician, airway obstruction is a concern.

Age

Pharyngitis occurs with much greater frequency in the pediatric population. GABHS is also more common in school-aged children. GABHS causes less than 15% of all adult cases of pharyngitis and about 15-30% of pediatric cases.

The peak incidence of bacterial and viral pharyngitis occurs in the school-aged child aged 4-7 years.
Pharyngitis, especially GABHS infection, is rare in children younger than 3 years.
Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus peak as causative agents in people in the teen years through the young adulthood years.

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