Pharyngeal Erythema Research Articles

A Case Report on Idiopathic Severe Bullous Pemphigoid

Bullous Pemphigoid (BP) is an autoimmune disorder which exploits the immune system and affecting sub-epidermal region of skin causing mild itching to infection and blistering of sub-epidermal region. Clinical presentations are pruritis, urticarial, papular lesions. These later evolve to bullae in weeks to months and are typically present in the axillae, on the flexor surface of the forearms, medial thighs, trunk, and abdomen. The treatment for bullous pemphigoid is systemic corticosteroids, topical steroids in combination with nicotinamide plus tetracycline, minocycline or doxycycline have shown success in multiple cases. Immunosuppressive therapy is used when steroids do not control the disease or if patients have contraindications for systemic corticosteroid treatments. Patient was brought to emergency department with chief complaints itching, redness, bullous lesion all over the body for 2 months.Oral complaints including solitary erosion seen on right side of buccal mucosa, pharyngeal erythema. Laboratory investigations were carried out. Patient was diagnosed based on physical examination. Patient was provided with adequate treatment and counseling.
 Keywords: Bullous Pemphigoid, corticosteroid, Autoimmune disorder, sub-epidermal region.

37-Year-Old Woman With Bilateral Lower Extremity Edema, Proteinuria, and Microscopic Hematuria

37-Year-Old Woman With Bilateral Lower Extremity Edema, Proteinuria, and Microscopic Hematuria

Chest And Neck Pain In A Tennis Player

HISTORY: An 18-year old male D-1 tennis player presented to the office with new onset pain in his chest and neck. It started the night prior to presentation in the center of his chest. He fell asleep without pain, but the next day noted pain in his upper chest and neck. He described it as a stiffness and as a weight pressing down on his chest. The pain was constant and worse with swallowing, speaking, neck extension, and head rotation. He also reported feeling more out of breath than usual. Two days prior to symptom presentation, he performed baseline strength testing. He denied fevers, pain with neck flexion, radiation to either arm, syncope, wheezing, sore throat, N/V/D or headache. He had no personal or family history of asthma, pneumothorax, or cardiac disease. He denied current or prior smoking, drug use, and vaping. PHYSICAL EXAM: Vitals: Ht 182 cm, Wt 77.1 kg, BP 119/74, HR 74 bpm, Temp 36.6 C (oral), BMI 23.2 Gen: NAD, nontoxic ENT: no pharyngeal erythema or tonsillar swelling Neck: no lymphadenopathy. Supple, full ROM but pain in full extension. No TTP of spine or soft tissues. CV: RRR, no M/R/G Resp: CTA bilaterally, good air entry, no wheeze, no accessory muscle use Chest: No TTP of ribs, sternum, costo-sternal joint, or intercostal spaces. No palpable subcutaneous crepitus to the chest or neck. Skin: no erythema of the skin of neck or chest DIFFERENTIAL DIAGNOSIS: Acute coronary syndrome Pneumomediastinum Strain Infection Asthma TESTING: X-ray of Chest/Neck: Lucency seen along paravertebral regions of upper thorax raising concern for pneumomediastinum. No pneumothorax. FINAL DIAGNOSIS: Spontaneous pneumomediastinum TREATMENT/OUTCOME: Patient was held from activity until follow-up weekly X-rays demonstrated resolution of free air in the neck. Symptoms and X-ray findings resolved within two weeks. He was cleared at 2 weeks with a gradual progression of activity and avoidance of full exertion or weight lifting. One week later, he was cleared to return to full activity with no restrictions. He was advised to avoid breath-holding with activity. He has had no recurrence of symptoms.

ENT manifestation in COVID-19 patients

Objectiveto detect, analyze and discuss the different ear nose throat (ENT) manifestations those were reported in COVID19 positive patients in the reviewed and published literatures. MethodsWe performed a search in the PubMed databases, Web of Science, LILACS, MEDLINE, SciELO, and Cochrane Library using the keywords; COVID-19, Novel coronavirus, corona, 2019-nCoV, SARS-CoV-2, ENT, ear, nose, throat, otorhinolaryngology, ORL, pharynx, ORL, smell, larynx, different ENT related symptoms. We reviewed published and peer reviewed studies that reported the ENT manifestations in COVID-19 laboratory-confirmed positive patients. Resultswithin the included 1773 COVID-19 laboratory-confirmed positive patients, the most common ENT manifestations of COVID-19 were sore throat (11.3%) and headache (10.7%). While the other reported ENT manifestations were pharyngeal erythema (5.3%), nasal congestion (4.1%), runny nose or rhinorrhea (2.1%), upper respiratory tract infection (URTI) (1.9%), and tonsil enlargement (1.3%). ConclusionENT manifestations for COVID-19 are not common as fever and cough. But, a universal questionnaire using well-defined COVID-19 manifestations is needed to make the COVID-19 data precisely defined, complete and homogenous.

Do Laryngologists and General Otolaryngologists Manage Laryngopharyngeal Reflux Differently?

To investigate current practices of laryngologists and non-laryngologists in management of Laryngopharyngeal Reflux (LPR). An online survey was sent to members of otolaryngology societies about LPR, and subgroup analysis was performed between laryngologists and non-laryngologists. This survey was conducted by the LPR Study Group of Young Otolaryngologists of the International Federation of Otolaryngological Societies. A total of 535 otolaryngologists completed the survey. Among them, 127 were laryngologists and 408 were non-laryngologists. Collectively, symptoms most commonly attributed to LPR are cough after lying down/meal, throat clearing, and acid brash; most common findings are thought to be arytenoid erythema and posterior commissure hypertrophy. Respectively, 12.5% and 5% of non-laryngologists and laryngologists believe that ≥50% of LPR patients suffer from heartburn (P = .010). Non-laryngologists are more aware about some extra-laryngeal findings associated with LPR (eg, pharyngeal erythema) than laryngologists. Neither laryngologists nor non-laryngologists associated development of benign lesions of the vocal folds with reflux. The management of LPR substantially differs between groups, with laryngologists indicating increased awareness of (impedance)-pH monitoring as well as the prevalence and treatment of nonacid/mixed LPR. Conversely, non-laryngologists are much more likely to include gastroenterology referral in their management of presumed LPR. Respectively, 44.8% and 27.6% of non-laryngologists and laryngologists believe themselves not sufficiently knowledgeable about LPR. Significant differences exist between laryngologists and non-laryngologists in diagnosis and treatment of LPR. Overall only one-third of responders believe themselves to be sufficiently educated about LPR. 4 Laryngoscope, 130:E539-E547, 2020.

Safety and immunogenicity of a replication-deficient H5N1 influenza virus vaccine lacking NS1

BackgroundTraditional inactivated influenza vaccines are the type of vaccines that were most frequently developed for immunization against the highly pathogenic avian H5N1 influenza virus. However, clinical trials with inactivated influenza vaccines for H5N1 indicated that high doses and at least two immunizations are required for an effective immune response (Nicholson et al., 2001; Treanor, Campbell et al., 2006; Treanor, Schiff et al., 2006; Ehrlich et al., 2008). We investigated the safety and immunogenicity of a live attenuated H5N1 vaccine (delNS1-H5N1) lacking the interferon antagonist nonstructural protein 1 (NS1). MethodsWe conducted a double-blind, placebo-controlled, phase 1 study in healthy adult participants who were randomly assigned at a 2:1 ratio to receive two immunizations of delNS1-H5N1 vaccine at 6.8 log10 50% tissue culture infectious doses (TCID50)/subject or 7.5 log10 TCID50/subject, or placebo. ResultsIntranasal vaccination with the live attenuated delNS1-H5N1 vaccine was safe and well tolerated. The most common adverse events identified were symptoms associated with mild influenza infections, such as increased body temperature (>37.0 °C), pharyngeal erythema, rhinitis and throat irritation, and were reported within 7 days after the first immunization. delNS1-H5N1 was able to induce significant vaccine-specific serum antibody titers even at the lower dose level of 6.8 log10 TCID50/subject. Seroconversion occurred in 75% of study participants after only one immunization with 7.5 log10 TCID50/subject. Vaccine-specific local IgA responses were observed in 41.7% of individuals that showed serum antibody responses after 2nd immunization. ConclusionsWe show that vaccination with a live attenuated H5N1 influenza vaccine lacking NS1 is safe and induces significant levels of vaccine-specific antibodies even after one immunization. The safety and immunogenicity data indicate that delNS1-H5N1 has the potential to fulfil the unmet need for an effective influenza vaccine in pandemic situations. (ClinicalTrials.gov identifier NCT03745274).

Microscopic polyangiitis after streptococcal pharyngitis in a young woman

A 36-year-old woman with insignificant medical history presented to the emergency department with high fever and sore throat. Her body temperature was 38.5°C and pharyngeal erythema was observed. The rapid...

A Rare Case of Primary Herpes Esophagitis in an Immunocompetent Young Adult

Introduction Herpes Simplex Viral (HSV) esophagitis is an opportunistic infection that is seen in patients with impaired immunity. It is rarely seen in immunocompetent individuals. It may result from direct spread to the esophagus from an oro-pharyngeal infection or can occur in patients with latent HSV by reactivation of the virus and dissemination to the esophageal mucosa via the vagus nerve. A few cases of HSV in immunocompetent individuals have been reported. We present a case of primary HSV esophagitis in an immunocompetent young adult whose biopsy was positive for both HSV 1 & 2. Clinical Vignette A 21 y/o male presented to the ED with complaints of sore throat, odynophagia and chest pain. Symptoms started as low grade fevers and viral-like illness and then progressed to throat soreness followed by severe odynophagia. Other symptoms included nausea, vomiting, subjective fevers, abdominal pain with radiation to the back during swallowing. Patient had no known past medical history, no history of cold sores and endorsed heterosexual activity with approximately twenty lifetime sexual partners and denied use of barrier contraception or engaging in oral sex. Physical examination was remarkable tonsillar erythema and edema, with mild pharyngeal erythema & exudates on tonsils. Blood tests were remarkable for positive HSV 1 &2 IgM and negative for HIV, CMV & EBV. CT neck showed bilateral tonsillitis, thickening of the esophagus, no evidence for peritonsillar abscess. Upper endoscopy revealed esophagitis manifested as edema, erosion and friable mucosa with spontaneous bleed on contact. Biopsy and pathology results was positive for herpes virus 1 &2. Further work up for underlying immune deficiencies and autoimmune diseases was negative. Patient was treated with oral acyclovir for 7days with resolution of symptoms. Discussion Very few cases of HSV esophagitis in immunocompetent individuals have been reported. It is mostly seen in immunocompromised individuals such as HIV carriers, transplant recipients, people on immunosuppressive agents and those with cancer. Initial symptoms usually include a viral prodrome followed by sore throat with odynophagia. Other common manifestations are dysphagia, retrosternal chest pain, weight loss, fever, nausea and vomiting. It is diagnosed via endoscopic inspection and histopathology findings. Treatment is with acyclovir, famiciclovir or valaciclovir. Symptoms may resolve over time with symptomatic treatment.1709_A Figure 1. Endoscopic findings1709_B Figure 2. Histology of HSV infected cells1709_C Figure 3. Immunohistochemical staining showing HSV infected cells

Epstein-Barr Virus Mucocutaneous Colonic Ulcer in an Immunocompetent Patient

Epstein Barr virus (EBV) positive mucocutaneous ulcers (MCU) were first described in 2010 in immunosuppressed individuals. Lesions have been noted in the oral mucosa, skin, and gastrointestinal tract. Although these lesions are typically benign and will heal with conservative therapy with reversal of immunosuppression, rare reports have described progression to disseminated Hodgkin's lymphoma (HL). We report a case of EBVMCU in an immunocompetent patient during a period of active EBV infectious mononucleosis superimposed on campylobacter colitis. A 47-year-old, previously healthy male presented to the hospital for evaluation for a 1-month history of bloody diarrhea associated with recent development of pharyngitis and flu-like symptoms. Physical exam noted pharyngeal erythema, symmetrical bilateral cervical lymphadenopathy with diffuse abdominal tenderness to palpation. Initial labs noted normal hemoglobin and WBC with a lymphocyte predominance. Transaminases were elevated with an AST 202 U/L, ALT 410 U/L and an alkaline phosphatase of 870 U/L. CT of his abdomen and pelvis revealed circumferential thickening of the rectum with inflammatory stranding, diffuse pelvic, abdominal, and thoracic lymphadenopathy, splenomegaly, and multiple hepatic lesions: collectively concerning for malignancy. Serum AFP, CEA, CA 19-9, and HIV markers were normal. Fecal calprotectin was elevated over 830ug/g. Hepatic MRI noted presence of cysts. Stool cultures were positive for campylobacter. He was started on azithromycin and after several days of therapy, symptoms did not improve. Colonoscopy revealed several clean based ulcers in the rectum and sigmoid-colon (Figure 1) with biopsies positive for EBVMCU (Figure 2). Serum EBV IgM was positive. He was ultimately discharged in stable condition with instructions for close follow-up. To date, 51 cases of EBVMCU have been described in the literature, 5 of which developed within the colon. All reports describe a predisposing factor of immunosuppression by either medication or age-related immunosenescence in patients >60. We report a presumed novel case in which colonic EBVMCU developed in a young immunocompetent patient during active EBV infection superimposed with campylobacter colitis. It is imperative to keep a broad differential and investigate persistent symptoms despite a diagnosis. EBVMCU falls on a spectrum of EBV-associated proliferative disorders, including HL, thus close surveillance is needed to ensure disease resolution.Figure: Colonoscopy acquired images depicting several clean based rectal ulcers.Figure: (Left) H&E stain of rectal ulcer noting colonic mucosa with dense lymphoplasmacyctic infiltrate. (Right) EBV in situ hybridization indicating presence of EBV DNA within the nuclei of infected cells.

Pneumomediastinum in a Young Previously Healthy Patient with Odynophagia: An Incidental Finding in the Emergency Room

Pneumomediastinum in a Young Previously Healthy Patient with Odynophagia: An Incidental Finding in the Emergency Room

Herpes Esophagitis in an Immunocompetent Host

Introduction: Esophagitis caused by HSV is well documented in immunocompromised patients. It is one of the AIDS defining illnesses however there are few cases documented in immunocompetent patients. Corticosteroids and chemotherapies are known risk factors for visceral herpes infections. Steroids are able to inhibit activation, proliferation and differentiation of all cells involved in mounting an immune response, such as T cells. Chemotherapy agents have immunosuppressive effects and cause loss of normal esophageal mucosal integrity, enhancing herpes reactivation. Most immunocompetent affected hosts experience odynophagia, fevers, respiratory symptoms, and dysphagia with anorexia. It generally affects the mid to distal part of the esophagus. In a symptomatic immunocompetent host, the symptoms should be self-resolving. In immunocompetent patients, herpes esophagitis may be a primary infection whereas in an immunocompromised patient, it may be a sign of reactivation of a latent infection. On endoscopy, herpes esophagitis presents as friable mucosa, numerous ulcers, and white exudates involving mid to distal esophagus. The diagnosis is based on endoscopic findings and confirmed by histopathological examination of the lesions, where it appears as ground glass nuclei and multinuclear giant cells. Acyclovir has shown improvement of symptoms in patients that are immunocompromised or immunocompetent. Case Report: 36-year-old female presented with complaints of dysphagia for 2 months. She reported gastroenteritis, fever and genital lesions prior. Her past medical history consisted of migraines and oral candidiasis. Methods: Physical was only significant for mild posterior pharyngeal erythema and moist mucous membranes. Labs were significant for negative HIV titers, positive HSV IgM, EBC IgG and CMV IgG. She underwent an EGD that revealed esophagitis typical of HSV in the middle third of the esophagus and multiple biopsies were taken. Results: All biopsies were negative for HSV. She was started on acyclovir, which led to symptom resolution. Discussion: In healthy patients, esophagitis occurs acutely and is self-limiting. The case presented is that of an immunocompetent patient with negative HIV titers and symptomatic dysphagia. Biopsies during EGD were still negative for HSV however the lesions seen on EGD were typical for HSV. Instead of being self-limited as has been described in other cases, her symptoms were relieved only after treatment with acyclovir.Figure 1

Respuesta al tratamiento en pacientes con enfermedad por reflujo Faringo-Laringeo. Puerto Padre, Cuba

Five adult patients diagnosed reflux disease pharyngo-laryngeal treated at the Department of Otolaryngology, ”Guillermo Dominguez Lopez” Hospital of the city of Puerto Padre, Cuba longitudinal intervention study was performed in sixty between April two thousand eight February two thousand XI for evaluating the therapeutic clinical response to treatment thereof. Age, sex, toxic habits, personal medical history, reported symptoms, physical findings and endoscopic examination, and response to treatment to the three and six-month followup: the variables were analyzed. Reflux disease pharyngolaryngeal, was presented with the highest incidence in women and in people over thirty-eight, and was commonly found toxic habits coffee and smoking, and history of obesity and digestive ulcer disease. The most common symptom was pharyngeal foreign body sensation; and most were found signs of erythema and the posterior pharyngeal wall erythema and hyperemia of the posterior commissure. In more than half the cases I prevailed endoscopic stage. It demonstrated that treatment should be extended for six months or more to achieve regression of signs and symptoms in a signi?cant number of patients.

Explosive Pleurisy Related to Group A Streptococcal Infection: A Case Report and Literature Review

Group A Streptococcus (GAS) can cause invasive infections, such as pneumonia. It is rarely associated with a rapidly progressing exudative pleural effusion termed explosive pleurisy, leading to significant morbidity and mortality. A 27-year-old healthy man devel - oped sore throat 1 week prior to admission and then progressively developed fever, chills and shortness of breath. Upon presentation, his vitals were remarkable for an oral temperature of 102.4 F, blood pressure of 89/64, heart rate of 124, respiratory rate of 40 and a pulse oximeter reading of 84%. Examination revealed pharyngeal erythema and exudates, and decreased right chest expansion with diminished breath sounds and dullness to percussion on the right. Labs revealed leukocytosis of 13,000/mcl White Blood Cells (WBC) (Normal 3,500-10,500 cells/mcl). Chest radiographs showed early pneumonia with a small pleural effusion. A CT scan of the chest was performed 4 hours later, revealing the presence of right middle and lower lobe pneumonia and a moderate-sized pleural effusion. A chest tube was placed and drained serosanguinous fluid. Cultures of the pleural fluid grew GAS. The patient was treated with intravenous Penicillin G and Clindamycin. The patient continued to deteriorate, despite antibiotics and the empyema worsened despite presence of a chest tube. Video Assisted Tho- racoscopic Surgery (VATS) with decortication and drainage was performed with significant improvement of the patient's condition. GAS pneumonia can progress rapidly with develop- ment of complicated parapneumonic effusions and empyema, the so-called 'explosive pleu- risy'. Early surgical intervention may result in quicker symptom resolution and may minimize morbidity.

Primary Pemphigus Vulgaris of the Esophagus

Pemphigus vulgaris (PV) is an autoimmune blistering disease associated with symptomatic involvement of the skin and mucous membranes. Most patients present with fragile, bullous oral lesions. Though the esophagus is lined with stratified epithelium, PV rarely involves the entire esophagus1. Prior study has shown that patients with esophageal involvement manifest as dysphagia (57%) and odynophagia (21%), whereas hematemesis is seen in only 3.5% cases2. Here we describe an atypical case of PV isolated to the esophagus wherein endoscopy was critical in diagnosis. A 48 year-old male with no significant medical problems presented with a 2-month history of dysphonia and pharyngeal discomfort with associated 20-pound weight loss. He described severe, sharp pain localized to the posterior tongue and pharynx, worse with swallowing. He had tried Azithromycin without improvement in symptoms causing him to seek further care. His exam showed injected conjunctiva, palatal and pharyngeal erythema with white exudates on the tongue. He was started on Nystatin for presumed fungal esophagitis, laryngoscopy showed oropharyngeal white patches, but with negative cultures. Initial EGD showed friable, erythematous mucosa with severe esophagitis; biopsies were consistent with Herpes Simplex, thus the patient was started on Acyclovir. He had persistent symptoms on week 2 of Acyclovir treatment. This prompted a repeat EGD which revealed circumferential erythema, mucosal sloughing involving almost the entire esophagus to the gastroesophageal junction (Figure 1). The biopsies showed suprabasilar acantholysis with papillomatous features and scattered dyskeratotic cells most consistent with PV (Figure 2). Subsequently he was seen by dermatology, who initiated steroid therapy resulting in a dramatic response.Figure 1Figure 2This case highlights the importance of endoscopy in the diagnosis of primary esophageal PV, especially in the absence of skin lesions. Dysphagia and odynophagia are common presenting symptoms in esophageal PV, similar to infectious esophagitis. Physical exam is often nonspecific resulting in an incorrect diagnosis and improper treatment. Evaluation with upper endoscopy is prudent in patients with unclear diagnosis in order to properly guide management.

Is it Necessary to initiate antibiotic therapy in children with pharyngitis

Streptococcuscus Beta Hemolytic Group A is the most important pathogen causing which may lead to purulent and non purulent angina. Rheumatic fever is the most important complication that is the cause of 30% to 40% of cardiac disease and disablement. This study was performed to evaluate prevalence of Streptococcuscus Beta Hemolytic Group A and estimate role of clinical findings in children with Streptococcuscus angina diagnosis. antibiotic resistance was also assessed evaluated in the patients with bacterial pharyngitis. Throat culture was performed on 104 patients referred to Amiralmomenin hospital of Semnan at the age range of 5 to 15 years having angina without begin on antibiotic treatment after the completion of the questionnaire. A frequency of 1% have been assessed for Streptococcuscus Beta Hemolytic Group A, coagulase -positive Staphylococci and non-group A Streptococcuscus frequencies were 10.6% and 17.3% respectively. 100% of patients had pharyngeal erythema, 72% had fever, 55% had exudates and 52% had cervical adenopathy. The diagnosed Streptococcuscus was sensitive against penicillin, erythromycin and amoxicillin and resistant against cotrimoxazole. In examining Staphylococcus aureus antibiotic-resistance, only 40% of cases were sensitive to clindamycin and 40% were also sensitive to vancomycin. Very low frequency of group A Streptococcuscus has undermined the routine use of antibiotic and show that the clinical based diagnosis alone is not reliable and rational use of antibiotics requires the use of other diagnostic methods such as throat culture and rapid antigen test (RATs). Also in analyzing coagulase -positive Staphylococci antibiotic resistance, we can see increased cases of resistance against neomycin and clindamycin which indicates the necessity of rational treatment of patients afflicted by strep to coccal infections.

Group A Streptococcus and hepatitis – streptococcal toxic shock syndrome

Group A streptococcal infection is common and has varied presentations. Group A streptococcus (GAS) is known to cause throat infections, erysipelas, scarlet fever and impetigo. Other more serious diseases caused by GAS are rheumatic fever and post streptococcal glomerulonephritis. There have been case reports showing an association with scarlet fever and jaundice postulating a direct effect of the erythrogenic toxin on the liver. We describe two cases; the first was a 13-year-old male who presented an atypical presentation of streptococcal infection with an acute hepatic picture who later developed septic arthritis, the second was a 7-year-old male who presented with disseminated intravascular coagulopathy, sepsis, jaundice and hepatic encephalopathy. In neither of the two cases did the children develop rashes of scarlet fever, desquamation or pharyngeal erythema. These were unique presentations highlighting the wide spectrum of GAS disease.

Oral health status among Iranian veterans exposed to sulfur mustard: A case-control study.

Background Sulfur mustard (SM) is a chemical warfare agent that has been repeatedly used since World War I. SM has chronic and deleterious effects on different body organs such as lungs, skin and eyes.Objectives To determine dental and oral health status of chemical victims of SM who were exposed to SM during the Iraqi-Iran war. Material and Methods In this case-control study, 100 male subjects exposed to SM were chosen as cases, and 100 non-exposed volunteers were chosen as controls. These groups were selected randomly according to their referral number, and were matched regarding age. Collection of information was performed using Oral Health Assessment Form designed by the World Health Organization. Quantitative and qualitative data were compared between the groups using independent samples t-test and Chi-square test, respectively. Results There was a significant difference between the case and control groups with respect to the frequencies of oral candidiasis, pharyngeal erythema and/or hyperplasia, hairy tongue and reflux disease, being higher in the former group. There was also a positive association between the frequency of candidiasis and the percentage of disability; pharyngeal erythema and/or hyperplasia and use of salmeterol spray; and between hairy tongue and antibiotic use in the case group. Conclusions Exposure to SM and the use of drugs for controlling long-term complications does not increase the risk of tooth decay, tooth loss, and intra and/or extra oral lesions in patients, but may be associated with increased incidence of oral candidiasis, pharyngeal erythema and/or hyperplasia, hairy tongue and reflux disease.samples of oral precancerous and cancerous lesions to test sensitivity and specificity and thus validate the clinical applicability of fluorescence imaging in (pre)cancerous diagnostics. Key words:Sulfur mustard, oral health, candidiasis.

A strange rash with "gloves and socks" distribution.

A strange rash with "gloves and socks" distribution.

Progressive left-sided facial swelling and proptosis.

Case Presentation A previously healthy 87-year-old African-American man presented to an urgent care facility with left nasal congestion. He reported a twoweek history of nosebleeds, low-grade fever, night sweats and general malaise. He was treated with intravenous ceftriaxone and prescribed oral levofloxacin for suspected acute bacterial sinusitis. Due to worsening symptoms, left eye swelling and continued bloody nasal discharge, he went to a local emergency department and was admitted to the hospital and treated with intravenous ampicillin plus sulbactam for community-acquired acute bacterial rhinosinusitis; however, despite empirical therapy, his facial swelling progressed to involve the periorbital region. He developed left facial numbness, proptosis and decreased vision in the left eye (Figure 1). On examination, he was afebrile and his heart rate was 82 beats/min, respiratory rate was 23 breaths/min and blood pressure was 130/86 mmHg. The patient was alert and cooperative. He had a small amount of bloody nasal discharge and left-sided facial swelling with tenderness noted in the maxillary area. Additional findings included left eye swelling without erythema that limited eye opening and examination. There was no pharyngeal erythema or oral lesions. He had no cervical adenopathy or organomegaly. There were no cutaneous or musculoskeletal findings. His respiratory, cardiovascular, abdominal and neurological examination were unremarkable. He had a white blood cell count of 170×109/L with 60% neutrophils, 8% bands, 16% monocytes, 14% metamyelocytes and 2% lymphocytes. He was anemic and thrombocytopenic; his hemoglobin level was 74 g/L and platelet count was 13×109/L. His prothrombin time was 17.9 s, partial thromboplastin time 34.5 s and international normalized ratio was 1.44. His plasma chemistry, including liver function tests and blood glucose measurements, were normal. Magnetic resonance imaging of the brain with contrast demonstrated the presence of extensive left-sided sinusitis involving the frontal, sphenoid, ethmoid and maxillary sinuses, with intraorbital extension of infection to the left medial superior orbit. As part of management, debridement and left inferior turbinate biopsy was performed by ear, nose and throat surgery. Based on the patient’s history, physical examination and clinical findings, what is the most likely diagnosis?

Diagnóstico da faringoamigdalite estreptocócica em crianças e adolescentes: limitações do quadro clínico

ObjectiveTo assess the utility of clinical features for diagnosis of streptococcal pharyngotonsillitis in pediatrics. MethodsA total of 335 children aged 1‐18 years old and presenting clinical manifestations of acute pharyngotonsillitis (APT) were subjected to clinical interviews, physical examinations, and throat swab specimen collection to perform cultures and latex particle agglutination tests (LPATs) for group A streptococcus (GAS) detection. Signs and symptoms of patients were compared to their throat cultures and LPATs results. A clinical score was designed based on the multivariate logistic regression analysis and also was compared to throat cultures and LPATs results. Positive throat cultures and/or LPATs results were used as a reference standard to establish definitive streptococcal APT diagnosis. Results78 children (23.4%) showed positivity for GAS in at least one of the two diagnostic tests. Coryza absence (odds ratio [OR]=1.80; p=0.040), conjunctivitis absence (OR=2.47; p=0.029), pharyngeal erythema (OR=3.99; p=0.006), pharyngeal exudate (OR=2.02; p=0.011), and tonsillar swelling (OR=2.60; p=0.007) were significantly associated with streptococcal pharyngotonsilitis. The highest clinical score, characterized by coryza absense, pharyngeal exudate, and pharyngeal erythema had a 45.6% sensitivity, a 74.5% especificity, and a likelihood ratio of 1.79 for streptococcal pharyngotonsilitis. ConclusionsClinical presentation should not be used to confirm streptococcal pharyngotonsilitis, because its performance as a diagnostic test is low. Thus, it is necessary to enhance laboratory test availability, especially of LPATs that allow an acurate and fast diagnosis of streptococcal pharyngotonsilitis.