Rapid Streptococcal Antigen Test Research Articles

Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Acute Bronchitis and Pharyngitis.

BackgroundA major challenge for antibiotic stewardship programs is the lack of accurate and accessible electronic data to target interventions. We developed and validated separate electronic algorithms to identify inappropriate antibiotic use for adult outpatients with bronchitis and pharyngitis.MethodsWe used International Classification of Diseases, 10th Revision, diagnostic codes to identify patient encounters for acute bronchitis and pharyngitis at outpatient practices between 3/15/17 and 3/14/18. Exclusion criteria included immunocompromising conditions, complex chronic conditions, and concurrent infections. We randomly selected 300 eligible subjects each with bronchitis and pharyngitis. Inappropriate antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm, which was constructed using only data in the electronic data warehouse. Criteria for appropriate prescribing, choice of antibiotic, and duration were based on established guidelines.ResultsOf 300 subjects with bronchitis, 167 (55.7%) received an antibiotic inappropriately based on chart review. The electronic algorithm demonstrated 100% sensitivity and 95.3% specificity for detection of inappropriate prescribing. Of 300 subjects with pharyngitis, 94 (31.3%) had an incorrect prescribing decision. Among 29 subjects with a positive rapid streptococcal antigen test, 27 (93.1%) received an appropriate antibiotic and 29 (100%) received the correct duration. The electronic algorithm demonstrated very high sensitivity and specificity for all outcomes.ConclusionsInappropriate antibiotic prescribing for bronchitis and pharyngitis is common. Electronic algorithms for identifying inappropriate prescribing, antibiotic choice, and duration showed excellent test characteristics. These algorithms could be used to efficiently assess prescribing among practices and individual clinicians. Interventions based on these algorithms should be tested in future work.

Dermatologic Manifestations of Systemic Diseases in Childhood

Dermatologic Manifestations of Systemic Diseases in Childhood

Implantación de una prueba rápida de infección estreptocócica: ¿su uso también mejora la adherencia antibiótica?

ObjectiveTo evaluate the influence of the result of a rapid streptococcal antigen test in paediatric pharyngotonsillitis infections, in terms of improvement of antibiotic therapy adherence. DesignRandomized community clinical trial with two study groups. LocationPrimary Care Centers in Central Catalonia. ParticipantsPatients aged from 3 to 15 years, who were attended at paediatric consultations on suspicion of pharyngotonsillitis caused by an infection between November 2010 and February 2011 (both included), were included in the study on a consecutive basis. 557 patients met the inclusion criteria and 519 were evaluated. InterventionThe control group received the usual diagnostic-therapeutic algorithm. Rapid streptococcal antigen test was additionally performed to experimental group participants and it was indicated the more convenient treatment. Main measurementsAntibiotic adherence, non-adherence causes and socio-demographic risk factors were evaluated via telephone survey. ResultsAntibiotics were prescribed to 65.6% and paediatricians of the control group were more likely to prescribe antibiotic than the ones in the intervention group (88.5% vs 45.5%, p< 0.0001). 64.8% followed doctor's treatment orders, being failure following medication scheduling the main cause of non-adherence (25.6%). Medication adherence was higher in the experimental group (68%) than in the control group (62.9%) but no significant differences were found. ConclusionRapid strep test, complementing the use of Centor Criteria avoids unnecessary antibiotics prescriptions, but had not been proven to be effective in increasing medication adherence.

Dysphagia and Epigastric Pain in an Adolescent Boy.

1. Senthil Velan Bhoopalan, MBBS, PhD* 2. Rabea Alhosh, MD† 1. *St. Jude Children’s Research Hospital, Memphis, TN 2. †University of Nevada Las Vegas, Las Vegas, NV A 17-year-old previously healthy boy presents with a history of epigastric abdominal pain associated with some difficulty in swallowing for the past 3 days. He denies any emesis but reports nausea. The abdominal pain is localized to the epigastric area without any radiation. Pain is reported at 7 on a scale of 1 to 10. He denies any diarrhea but had noticed a few episodes of black tarry stool for the past 2 days. His sexual history is significant for oral sex with a single female partner, but he denies any genital or oral lesions. He was seen by his pediatrician 2 days ago. His pediatrician suspected a gastric ulcer and prescribed him pantoprazole, which the patient never obtained. On presentation he has a temperature of 103°F (39.4°C) and appears mildly dehydrated. His vital signs are otherwise within normal limits. On physical examination the patient has dry lips and mucosa, but no oral lesions are noted. Mild epigastric tenderness without any rigidity or rebound tenderness is noted. Examination findings are otherwise normal. Initial laboratory evaluation shows a white blood cell count of 12,900/μL (12.9×109/L), and the remainder of the blood cell count and metabolic panel are normal. The results of the antigen test for influenza, the heterophile antibody test for infectious mononucleosis, and the rapid streptococcal antigen test are negative. His CRP level is elevated to 12 mg/dL (120 mg/L). A computed tomographic scan …

Efficacy of Rapid Antigen Test and McIsaac / Modified Centor Scores for Diagnosis of Streptococcal Tonsillopharyngitis in Children

Objective: We aimed to determine the efficacy of rapid antigen tests, clinical signs, and McIsaac / modified Centor clinical scoring systems in the diagnosis of Group A streptococcus (GAS) at children. Materials and Methods: Subjects aged 3-14 years who presented with acute tonsillopharyngitis were questioned about their sociodemographic properties and symptoms. Their clinical signs and McIsaac / modified Centor scores were recorded. They underwent a rapid streptococcal antigen test and throat culture sampling. Results: GAS proliferated in culture %11 of cases. The risk of culture positivity was 4.8 times greater in children aged 6 years or older. There was a significant correlation between culture positivity and muscle pain, tonsillar edema. Rapid strep test had a sensitivity of 75% and a specifity of 100% for the diagnosis of streptococcal tonsillopharyngitis. Rapid strep test showed a sensitivity of 80% and a specifity of 100% in children with a McIsaac / modified Centor score of 4-5. Conclusions: Unnecessary antibiotic use for tonsillopharyngitis is an important problem. Therefore, it is ideal to order throat culture and act accordingly in every case suggesting GAS infection. However, when culture is not possible, rapid strep testing and McIsaac / modified Centor scoring are effective in guiding diagnosis and treatment.

Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a crosssectional study in a tertiary care hospital.

Çağlar İ, Topal S, Çokboz M, Düzgöl M, Kara A, Bayram SN, Apa H, Devrim İ. Clinical features and laboratory findings in children hospitalized with acute Epstein-Barr virus infection: a cross-sectional study in a tertiary care hospital. Turk J Pediatr 2019; 61: 368-373. Epstein-Barr virus (EBV) is widespread all over the world. It causes infectious mononucleosis (IM) mostly in adolescents and adults. Although IM is considered to be rare in younger children and infants, acute EBV infection may have various manifestations in this age group. We aimed to describe the clinical features and laboratory findings of children hospitalized with acute EBV infection. All children hospitalized at Dr. Behçet Uz Children`s Hospital, between January 2010 and January 2017, who tested positive by presence of EBV-specific antibodies and had the diagnosis of acute EBV infection, were included (n=66). Thirty four of the patients (51.5%) were under 6 years of age, and 23 (34.8%) children were below 3 years of age. The most common physical finding was fever (92.4%) followed by cervical lymphadenopathy and tonsillopharyngitis. Leukocytosis (65.1%) and lymphocytosis (42.4%) were the most common laboratory findings. Reactive and atypical lymphocytes were present in 77.2% of the patients. Fifty-three (80.3%) of the patients had a doctor visit before hospitalization, and the ratio of patients using antibiotics was 77.3%. Skin rash was observed in 14 (27.4%) of the patients who used antibiotic treatment and in 2 (13.3%) of the patients who did not (p > 0.05). EBV infection resulting in admission to hospital is common in younger children, even in pre-school period. Serological tests for EBV specific antibody responses and peripheral blood smear evaluation are important diagnostic tools. In addition, rapid streptococcal antigen test and throat culture should be performed in patients presenting with tonsillopharyngitis in order to exclude Group A beta-hemolytic streptococci and reduce unnecessary antibiotic consumption.

Beta-Hemolytic Nongroup A Streptococcal Pharyngitis in Children

To evaluate the epidemiology, clinical features, and antibiotic prescribing patterns for nongroup A streptococci (NGAS) in children. Throat cultures obtained for pharyngitis were assessed at a large community-based health system over 10 years. Epidemiologic and clinical features of children with NGAS were compared with children with group A Streptococcus (GAS) and negative cultures. Antibiotic prescribing patterns were evaluated. A total of 224 328 rapid streptococcal antigen tests and 116 578 throat cultures were performed. Clinical analysis was completed for 602 GAS-positive patients, 535 NGAS-positive patients, and 480 patients with negative cultures. Incidence of NGAS did not vary annually or by season but increased with age from 2% at ≤5 years to 7% at 18 years of age. Patients with NGAS were more likely than those with negative cultures to have tonsillar exudate (20.3% vs 13.1%, P = .003) and enlarged tonsils (28.6% vs 19.3%, P < .001). Modified Centor scores did not differ between groups (score ≥2, P = 1.0; score ≥3, P = .50). Patients with GAS were more likely than those with NGAS to have fever (32.6% vs 24.5%, P = .003), palatal petechiae (14.0% vs 3.1%, P < .001), and modified Centor score ≥2 (47.8% vs 27.1%; P < .001). Of patients with NGAS, 65% were prescribed antibiotics. NGAS likely exist in both carriage and infectious states and incidence increases with age. Infections associated with NGAS are milder than with GAS, and complications are rare. Laboratory reporting of NGAS results in high antibiotic use, despite current recommendations against treatment.

Clinical Impact of a Rapid Streptococcal Antigen Test on Antibiotic Use in Adult Patients

IntroductionAdult pharyngitis is rarely attributable to group A streptococci. Utilization of a rapid streptococcal antigen test (RADT) may improve appropriate prescribing for bacterial pharyngitis. MethodsClinic 1 performed RADTs with subsequent Group A DNA probe test (GADNA) from November 2014-March 2015 and November 2015-March 2016 while Clinic 2 was the control clinic, then implemented the RADT with a GADNA from November 2015-March 2016. All GADNA results were obtained for each clinic from October 2013-March 2016. ResultsAt Clinic 1, 22.2% versus 8.5% of patients received inappropriately prescribed antibiotics for a GADNA or RADT result, respectively (p=0.048). For Clinic 2, 51.1% compared to 21.4% of patients were inappropriately prescribed antibiotic for a GADNA or RADT result, respectively (p=0.038). Overall, the total GADNA without RADT testing or RADTs with subsequent GADNA testing, 41.6% versus 11% of patients were inappropriately prescribed antibiotics, respectively (p=<0.0001). ConclusionUtilizing the RADT prevented unnecessary prescribing of antibiotics in adults.

A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic.

BACKGROUND:Inappropriate use of antimicrobial agents is the major cause for the development of resistance. Thus, it is important to include outpatient clinics in the development of antibiotic stewardship program.METHODS:We report a multifaceted approach to decrease inappropriate antibiotic use in upper respiratory tract infections (URTIs) in an outpatient pediatric clinic. The interventions included educational grand round, academic detailing, and prospective audit and feedback and peer comparison.RESULTS:During the study period, a total of 3677 outpatient clinic visits for URTIs were evaluated. Of all the included patients, 12% were <1 year of age, 42% were 1–5 years, and 46% were >5 years of age. Of the total patients, 684 (17.6%) received appropriate antibiotics, 2812 (76.4%) appropriately did not receive antibiotics, and 217 (6%) inappropriately received antibiotics. The monthly rate of prescription of inappropriate antibiotics significantly decreased from 12.3% at the beginning of the study to 3.8% at the end of the study (P < 0.0001). Antibiotic prescription among those who had rapid streptococcal antigen test (RSAT) was 40% compared with 78% among those who did not have RSAT (P < 0.0001).CONCLUSIONS:The combination of education and academic detailing is important to improve antibiotic use.

A Rare Gastrointestinal Complication of Henoch Schonlein Purpura in an Adult

INTRODUCTION: Henoch-Schonlein purpura (HSP) is an IgA mediated small-vessel vasculitis commonly seen in a 3-15 years of age group; characterized by classic tetrad of arthralgia, palpable purpura without thrombocytopenia or coagulopathy, renal and gastrointestinal involvement along with leucocytoclastic vasculitis. The most common gastrointestinal complication is intussusception. CASE PRESENTATION: A 39-year-old male with no significant past medical history presented with 2-day history of nausea, vomiting, abdominal pain and diarrhea. CT abdomen with contrast showed dilation of third portion of duodenum and proximal jejunum with significant wall thickening and collapsed appearance of small bowel further downstream suggestive of closed-loop obstruction. Emergent exploratory laparotomy following this showed midgut volvulus causing small obstruction which was reduced without the need for bowel resection. On post-operative day 3, he developed hematuria with urinalysis positive for protein and RBCs. Total protein/creatinine ratio was 1.2 consistent with significant proteinuria but stable BUN and creatinine. Palpable purpura was noted on his legs bilaterally with spread up to his buttocks. He initially noticed this rash 2 days prior to admission which had since progressed. Serum C3, C4, cryoglobulins, IgA and ANA were negative. Skin biopsy demonstrated leucocytoclastic vasculitis with predominance of IgA deposition on DIF consistent with HSP. On further questioning, patient confirmed an episode of upper respiratory tract infection 2 weeks prior to admission. Streptococcus O antibody titer was elevated but rapid streptococcal antigen test was negative. Lisinopril was started for proteinuria. Both, hematuria and proteinuria decreased with stable renal functions at discharge and thus corticosteroids were not indicated. DISCUSSION: HSP, a self-limiting condition, though common in pediatric population but few cases have been reported in adults as well. Gastrointestinal involvement occurs in about two-third of children. Intussusception is the most common complication. Bowel ischemia/infarction, intestinal perforation, fistula formation, acute appendicitis, pseudomembranous colitis, pancreatitis and upper gastrointestinal bleed though infrequent, have also been reported. Volvulus is a very uncommon complication in HSP. Thus, it is important to bear in mind the various presentations of HSP and it should be among differentials even in adults when the suspicion is high.

Clinical Manifestations of Group A Streptococcal Pharyngitis and Comparison of Usefulness of Two Rapid Streptococcal Antigen Tests

This article is available from http://www.labmedonline.org 2016, Laboratory Medicine Online This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Background: Throat culture is the golden standard for diagnosis of group A streptococcal (GAS) pharyngitis. However, because it is a time-consuming procedure, antibiotics are often empirically administrated. Rapid antigen tests (RATs) can detect bacterial infections within 15 minutes, thus helping to reduce unnecessary administration of antibiotics. Methods: In total, 108 patients, between 3 and 17 yr of age, who visited our hospital from August 2011 to July 2012, were tested for suspected acute pharyngitis with two RATs––SD Bioline Strep A (SD, Korea) and BinaxNOW Strep A (Binax, Inc., USA)––as well as throat culture. We compared the sensitivity, specificity, and consistency of the two RATs and assessed the clinical manifestations of GAS pharyngitis. Results: Of the 108 patients, 15 were confirmed to have GAS pharyngitis by throat culture. The SD test showed a sensitivity of 93.3% and a specificity of 97.8%; the positive and negative predictive values were 87.5% and 98.9%, respectively. The Binax test showed a sensitivity of 86.7% and a specificity of 100%; the positive and negative predictive values were 100% and 97.9%, respectively. The Kappa values for conformity degree were high, 0.887 and 0.918 in the SD and the Binax tests, respectively (P =0.00). Clinical manifestation assessment of GAS pharyngitis indicated that scarlatiniform rash and strawberry tongue were significantly associated signs (P <0.05). Conclusions: GAS pharyngitis diagnosis based on clinical manifestations alone has practical limitations. The two RATs are useful as substitutes for throat culture and their frequent use in clinical settings is advisable.

Streptococcus pyogenes Cervical Intertrigo with Secondary Bacteremia

We report a 12-month-old infant girl with cervical intertrigo caused by Streptococcus pyogenes. This form of intertrigo has been reported in only five children, but it is clearly underestimated. It should be suspected for well-demarcated beefy-red lesions of the neck not responding to antifungal therapy. A rapid streptococcal antigen test of a lesion specimen is a useful diagnostic tool. Our patient was notable for the development of S. pyogenes bacteremia, a complication that has not been previously associated with this condition.

Group A Streptococcus pharyngitis outbreak among university students in a judo club

We report on an outbreak of Group A Streptococcus (GAS) pharyngitis among university students in a judo club. Eventually, 14 of total 23 club members developed acute pharyngitis clinically. In a span of 15 days in April 2013, 12 students visited our hospital complaining of sore throat and high fever. All were men with a median age of 19.5 years (interquartile range, 18-21). The rapid streptococcal antigen test was positive in 3 of 4 patients (75%) without previous antibiotic treatment, and in 2 of 8 patients (25%) with previous antibiotic treatment. The definitive diagnosis of GAS pharyngitis was made by either a positive RADT or positive throat culture of GAS when patients had more than 2 findings from the Centor scoring system in this study. 5 students received the definitive diagnosis. The throat culture results showed that 1 out of 9 asymptomatic students was GAS-positive. The outbreak might have occurred by person-to-person contact while living in a dormitory and during judo training, which is a highly close-contact sport. However, there was also the possibility of oral transmission by the shared use of water bottles, although the culture from 1 bottle was negative. Some students continued to participate in the judo club activities after the onset of sore throat or fever. Healthcare professionals, teachers, and coaches should be aware of the potential outbreaks of infectious diseases among university students engaged in athletic activities. Furthermore, it is important to educate athletes about infectious diseases.

Index of Suspicion

Index of Suspicion

Index of Suspicion

A 5-year-old previously healthy boy presents to the emergency department (ED) with a 2-week history of intermittent left groin pain, usually occurring later in the day. Pain is not related to eating, movement, urination, or stooling. There is no report of trauma or precipitating event. He screams and refuses to stand up during pain episodes, which occur suddenly and last approximately 1 to 2 hours at a time. He otherwise has normal gait and activity when pain free. He does not wake up at night in pain. No recent illnesses or fevers are reported. Review of systems and his examination findings are unremarkable. Two days prior, he was evaluated in the ED for the same issue and had normal urinalysis, urine culture, and scrotal ultrasonogram results. The consulting urologist did not suspect a urologic process. He was discharged home with pain medication. Today, he returns to the ED because of the intense pain. The patient is admitted for further evaluation and pain management. Complete blood cell (CBC) count, C-reactive protein level, urinalysis results, and plain radiographs of the hips are unremarkable. Computed tomography of the abdomen and pelvis reveals a trace amount of nonspecific free fluid in the pelvis. His pain appears to be alleviated with ibuprofen and bed rest. The following day, he has another episode of intense groin pain after returning from the play room. Physical examination at this time demonstrates only point tenderness on palpation over his symphysis pubis area. No swelling, erythema, or increased warmth was noted in that area. An additional imaging study reveals the diagnosis. A 15-year-old girl presents to the clinic with an itchy rash, fever, headache, nausea, and dizziness. A few days earlier she was evaluated for rash on her back and low-grade fevers. She was prescribed amoxicillin clavulanate for suspected streptococcal …

Evaluation of the implementation of a rapid streptococcal antigen test in a routine primary health care setting

Pharyngitis is a common reason for consultation in General Practice. Despite the development of diagnostic criteria it remains difficult to clinically diagnose the bacterial type. Therefore, current guidelines recommend the additional use of objective tests. In Austria, the Burgenländische Gebietskrankenkasse introduced a test as service for patients and regular payment position for GPs. It was the aim of this study to analyze this implementation process in General Practice and a possible change in antibiotic prescriptions. The retrospective evaluation lasted from April 2006 to September 2009; in April 2007, rapid-streptococcal-antigen-tests (RSATs) were introduced. GPs were grouped into three clusters according to their use of RSATs. In addition, all antibiotic prescriptions within the evaluation period were analyzed and correlated to the three clusters before and after the implementation. The overall number of RSATs performed was 6,401. Half of the GPs utilized it regularly. After its introduction, the relative antibiotic prescription frequency was significantly reduced (17.1 vs. 16.4 %, p = 0.0001). The results for the subgroup analyses yielded a significant reduction for the regular user group only (16.0 vs. 15.0 %, p = 0.0001). GPs using the RSAT regularly seem to apply the test appropriately. The decrease of the relative antibiotic prescriptions of all GPs seems to be due to the regular user group of GPs. This could be interpreted as a consequence of the RSAT use. The results show a positive trend for an improvement in diagnostic quality and for an appropriate use of antibiotic prescriptions.

Visual Diagnosis: Swelling of the Left Side of the Neck in an Adolescent

1. Raghu Varier, DO* 2. Laura Plencner, MD* 3. Douglas Rivard, DO† 4. Angela L. Myers, MD, MPH* 1. *Department of Pediatrics, Children's Mercy Hospitals & Clinics and The University of Missouri-Kansas City, Kansas City, MO. 2. †Department of Radiology, Children's Mercy Hospitals & Clinics and The University of Missouri-Kansas City, Kansas City, MO. A previously healthy 13-year-old girl presents to the emergency department with a 2-week history of worsening sore throat and a 4-day history of left neck swelling, pain, and fever. Results of evaluation by a prior clinician at the onset of symptoms included a negative rapid streptococcal antigen test and a positive heterophile antibody test, prompting treatment with oral corticosteroids for 5 days as an anti-inflammatory medication. The girl now reports pain with swallowing, decreased oral intake, and left-sided head tilt for the past 24 hours. On physical examination, the girl has a temperature of 38.4°C and appears to be in no acute distress. In addition, her heart rate is 91 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 119/69 mm Hg. She has a warm, very tender, firm, anterior, left-sided 1.5-cm mass at the level of the thyroid gland. The mass moves when she swallows. Findings on the rest of her physical examination are normal. Laboratory investigation reveals a white blood cell count of 17.2×103/μL (17.2×109/L) with 74% neutrophils and 14% lymphocytes, hemoglobin of 13 g/dL (130 g/L), and platelet count of 423×103/μL (423×109/L). C-reactive protein (CRP) measurement is elevated at 1.6 mg/dL (normal, 0.3 to 1.0 mg/dL). Computed tomography (CT) scan of her neck with intravenous contrast enhancement suggests the diagnosis (Fig. 1). Figure 1. Axial computed tomography scan of the neck with intravenous contrast enhancement. The patient's physical and laboratory findings and CT scan of the neck are consistent with acute suppurative thyroiditis. The CT scan reveals a multilocular inflammatory phlegmon/abscess-in-evolution involving the superior pole of the …

Return of the usual suspect

In October, 2010, a 76-year-old woman born in the USA presented to our emergency department complaining of a severe sore throat and painful swallowing. She reported having had a non-productive cough without haemoptysis 1 month previously. The cough resolved, but a sore throat then developed. At the time she was assessed by her general practitioner and specialists in the emergency and otolaryngology departments, who diagnosed pharyngitis and recommended conservative management. Her odynophagia progressed until she was unable to eat solid foods, prompting her to present to our hospital. She denied fevers, chills, night sweats, myalgias, dysphonia, dyspnoea, or dysphagia but did report a 7 kg weight loss. She also reported occasional tobacco and alcohol use. On examination she was afebrile and thin but appeared well. She had dry mucous membranes and mild erythema of the posterior pharynx without tonsilar enlargement or exudate. No oral thrush, cervical lymphadenopathy, rales, splenomegaly, or rash were noted. Leucocyte concentration was 7·9 × 109/L with a predominance of neutrophils. She was admitted for further assessment. Rapid streptococcal antigen test, monospot test, human immunodefi ciency virus (HIV) antibody test, and rapid antigen test for infl uenza A and B were negative. A temperature of 38·7°C prompted a chest radiograph, which showed bilateral airspace disease and an area of dense consolidation in the right upper lung with a rounded lucency likely to be cavitation (fi gure A), subsequently confi rmed on chest CT (fi gure B). CT of her neck showed non-specifi c epiglottis oedema. Purifi ed protein derivative skin test was negative. A few acid fast bacilli were present in the sputum, and she was started on empiric therapy for presumed pulmonary tuberculosis. DNA probe performed on sputum confi rmed Mycobacterium tuberculosis which was sensitive to all antituberculous drugs tested. Subsequently, her fever and odynophagia resolved. Laryngeal tuberculosis was the most likely cause of our patient’s sore throat as evidenced by her clinical symptoms and presumed active pulmonary tuberculosis, the non-specifi c oedema of the epiglottis noted on CT, and the resolution of her sore throat and odynophagia with antituberculous therapy. However, a defi nitive diagnosis cannot be made without laryngoscopy and histopathological confi rmation; laryngoscopy was deferred because of the substantial infectious risk associated with the procedure in the setting of active tuberculosis. She was discharged with instructions for tuberculosis testing of close contacts and plans for direct observed therapy. At last contact in February, 2011, she was well, with no recurrence of symptoms. Laryngeal tuberculosis, which accounted for 25% of all cases of tuberculosis in the early 20th century, now accounts for less than 1% of cases and is typically associated with pulmonary infection. Whereas extrapulmonary tuberculosis occurs frequently in persons with HIV, cases of laryngeal tuberculosis have been reported in immunocompetent persons. Our patient presented with odynophagia, a common presenting complaint in patients with laryngeal tuberculosis, but she denied hoarseness, the most common presenting symptom. She denied any history of tuberculosis or known contact with persons with tuberculosis, but she did report having worked as a home health aide during the 1970s. Laryngeal tuberculosis results from either direct bronchogenic spread from infected sputum or, less commonly, haematogenous spread. Laryngeal tuberculosis is highly infectious, and a delay in diagnosis can lead to disease progression and longer exposure to contacts. Therefore, physicians should consider laryngeal tuberculosis in the diff erential diagnosis of patients presenting with a persistent sore throat and odynophagia, especially in patients such as ours who also report weight loss. A chest radiograph should be considered before laryngoscopy to minimise unnecessary risk to healthcare providers.

Visual Diagnosis: Sore Throat and Difficulty Swallowing in a 9-year-old Boy

1. Nirav Shastri, MD, FAAP* 2. Gretchen Black, DO* 3. Milton A. Fowler Jr, MD, FACEP† 1. *Assistant Professor of Pediatrics, University of Missouri, Kansas City, MO; Children's Mercy South Urgent Care Center, Overland Park, KS. 2. †University of Missouri, Kansas City, MO; Section Chief, Children's Mercy South Urgent Care Center, Overland Park, KS. A 9-year-old boy presents with sore throat and difficulty swallowing of 3 days' duration. He was seen at a clinic on the first day of his illness, where the result of a rapid streptococcal antigen test was negative. He was discharged with a diagnosis of sore throat with cough and prescribed a 5-day course of azithromycin and a 3-day course of prednisolone suspension. However, his sore throat has persisted and his dysphagia has worsened. His mother is seeking further medical attention because she has noted the roof of his mouth to be red and swollen posteriorly. The boy describes a feeling that “something is stuck in my throat” but still can swallow. Dysphagia occurs with both solids and liquid foods. On physical examination, his vital signs are within normal limits; there is no fever or respiratory distress. Examination of the pharynx reveals an erythematous, swollen uvula (Fig. 1). He has no drooling, cervical lymphadenopathy, or erythema or exudate on his pharyngeal wall. No …

Visual Diagnosis: Rash, Eye Pain, Lesions in an Adolescent

1. Sarah Powers, MD* 2. Gina Carter-Beard, MD† 1. *Department of Pediatrics, University of New Mexico School of Medicine, Santa Fe, NM. 2. †Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Ore. A 17-year-old boy presents to his primary care practitioner with a 3-day history of rash, bilateral eye irritation, and sores in his mouth and on his genitals. He had been seen in the emergency department approximately 1 week ago for fever and a sore throat. A rapid streptococcal antigen test was positive at that time, and he was started on oral azithromycin therapy. Four days later, he developed facial swelling, eye redness, and “hives,” appearing initially on his hands, then spreading to his legs and feet. Although his sore throat resolved, new and different oral lesions appeared, and his lips became chapped and painful, prompting him to go to an urgent care clinic, where his azithromycin therapy was discontinued and he was started on oral prednisone and diphenhydramine. However, his skin lesions and eye pain continued to worsen, and sores appeared on his genitals. When he developed dysuria, he presented to his primary care physician for additional evaluation. The patient reports a history of allergy to penicillin, manifesting as hives in the past. Except for this past week, he takes no medications. There is no family history of skin disease. He is a sophomore in high school and smokes a half pack of cigarettes daily. He acknowledges occasional binge drinking and daily marijuana use but denies the use of other illicit drugs. He has been sexually active since the age of 16 years and has had many female partners, including some intercourse without protection, but denies any history of sexually transmitted infection. Physical examination reveals an alert, thin, but well-nourished adolescent male. His temperature is 37.0°C, respiratory rate is 18 breaths/min, …