Recurrent Pharyngitis Research Articles

Treatment of acute pharyngitis in children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-FIMMG).

Sore throat represents one of the main causes of antibiotic overprescription in children. Its management is still a matter of debate, with countries considering streptococcal pharyngotonsillitis a benign and self-limiting condition and others advocating for its antibiotic treatment to prevent suppurative complications and acute rheumatic fever. Italian paediatricians frequently prescribe antibiotics on a clinical basis regardless of microbiological results. Moreover, broad-spectrum antibiotics are inappropriately prescribed for this condition. In this regard, an intersociety consensus conference was issued to promote the judicious use of antibiotic therapy in paediatric outpatient settings. A systematic review of the literature was performed, and updated recommendations were developed according to the GRADE methodology. Antibiotic treatment with amoxicillin (50mg/kg/day) for 10 days is recommended in all children with proven streptococcal pharyngitis. Benzathine-penicillin could be prescribed in children with impaired intestinal absorption or inability to tolerate enteral intake and in those at high risk of suppurative complications with low compliance to oral therapy. In children with suspected amoxicillin allergy, third-generation cefalosporins for five days are recommended in low-risk patients, and macrolides are recommended in high-risk ones. Candidates for tonsillectomy due to recurrent pharyngitis could be treated with amoxicillin-clavulanic acid, clindamycin, or combined therapy with amoxicillin plus rifampicin for four days, in an attempt to avoid surgery.

Efficacy of homoeopathic similimum in comparision with biochemic medicines in the management of recurrent pharyngitis: A randomized control trial

Efficacy of homoeopathic similimum in comparision with biochemic medicines in the management of recurrent pharyngitis: A randomized control trial

Periodic Fever in Children: A Report of Three Unusual Cases

Introduction: Periodic fever syndrome (PFS) is a rare monogenic autoinflammatory disease group. The innate immune system abnormalities have a characteristic onset and spontaneous inflammation without any infectious or autoimmune trigger. It differs from autoimmune disorders (e.g., systemic lupus erythematosus (SLE)) occurring due to a defect in the adaptive immune system with auto-antibodies. Case Presentation: The clinical features of three patients presented with a periodic pattern of fever and a different constellation of symptoms were investigated. The final diagnosis of Periodic fever syndrome was reached based on standard diagnostic criteria and genetic testing. All three cases were observed to present with recurrent fever episodes at an interval of 6 - 12 weeks, 3 - 4 weeks, and one month, respectively. The first patient, presenting with a diffuse erythematous plaque-like lesion along the calf with severe calf pain and tenderness with signs of meningeal irritation, was diagnosed with a tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS) like phenotype. The genetic panel was negative in this case. The second patient presenting with recurrent pharyngitis, cervical adenitis, and tonsillitis unresponsive to antibiotics was diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. The last patient presenting with recurrent monoarthritis, hepatosplenomegaly, and a positive Mediterranean fever (MEFV) gene mutation was diagnosed with familial Mediterranean fever (FMF). All three patients had normal growth and development. Conclusions: Although periodic fever syndrome was an uncommon entity, it was recommended that this syndrome should be considered when a patient presented with recurring fever episodes with a characteristic constellation of symptoms.

Acute tonsillopharyngitis - a review

Introduction and purpose: Acute pharyngitis and tonsillitis is the most common reason why people want to visit their primary care physician. Viruses are the most common cause of acute pharyngitis and acute tonsillitis in children and adults. The patient complains about pain with sudden onset and throat irritation, pain on swallowing, fever and headache, and in children also abdominal pain, nausea and vomiting.
 Brief description of the state of knowledge: Most acute tonsillopharyngitis is due to rhinoviruses (35%), influenza (30%), RSV and parainfluenza. Bacteria causes 30% of the infections and S. pyogenes is the most common cause. Viral infections are seasonal. S.pyogenes infection is most often in winter and early spring. Changes in the pharyngeal mucosa look similar in both bacterial and viral etiologies. Because of that, scales have been developed to assess the probability of a bacterial infection. The most used is Centor / McIsaac scale. The gold standard of diagnostics is throat swab culture. In the treatment of streptococcal pharyngitis and tonsillitis, penicillins are used as first-line treatment. Antibiotic treatment reduces infectivity, lowers the risk of rheumatic fever and made symptoms disappear two days earlier. Tonsillectomy does not reduce the number of recurrent pharyngitis and tonsillitis, therefore it cannot be recommended.
 Conclusion: Acute tonsillopharyngitis can result in many complications, the most serious of them is rheumatic fever. Therefore, it is very important to properly diagnose and use antibiotic therapy when necessary.

Lateral neck cyst surgery without ipsilateral tonsillectomy: a retrospective analysis

PurposeSeveral theories have been proposed regarding the origin of lateral neck cysts (LNC). Besides complete surgical resection ipsilateral tonsillectomy and dissection of a tract or its remnants is sometimes recommended. In this retrospective trial we wanted to evaluate if patients, who received LNC resection only, develop complications or recurrence to justify this surgical strategy.MethodsPatients who received LNC resection between 2004 and 2017 at the Ear Nose and Throat Department of a university hospital were included. Data was collected from the clinic database and through a structured telephone interview.ResultsA total of 126 patients met the inclusion criteria. In this collective, the diagnosis of a lateral neck cyst was confirmed histologically. Mean age at time of operation was 38 years (± 14.6). The median follow-up time was 7 years (range 3–18). None of the participants experienced recurrent unilateral pharyngitis or tonsillitis during follow-up. Furthermore, there was no case of postoperative peritonsillar, neck phlegmon or neck abscess. No patient reported recurrence of LNC.ConclusionsSole complete resection of LNCs is sufficient to avoid postoperative infections and recurrences. Therefore, ipsilateral tonsillectomy and tract dissection is not necessary in routine cases of LNC surgery.

Paediatric autoimmune neuropsychiatric syndrome in recurrent acute bacterial pharyngitis – a case report

Pharyngitis and tonsillitis, regardless of their aetiology, are one of the most frequent reasons for visiting a family doctor or a paediatrician. Nearly 85% of pharyngitis cases are viral. It is estimated that bacterial throat infection occurs in 15% of schoolage children and in 4–10% of adult patients. Streptococcus pyogenes is the most common cause of bacterial pharyngitis. PANDAS stands for paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. The term is used to describe a subgroup of children and adolescents who develop acute obsessive-compulsive disorder or tics as a result of group A streptococcal infection, such as tonsillitis. The aim of the paper is to describe a case of a 4-year-old boy who presented to the Laryngology Clinic due to recurrent tonsillitis, time-correlated with obsessive-compulsive disorder.

The role of inflammatory mediators in the pathogenesis of periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome.

As a recurrent disease, periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is characterized by episodes of febrile attacks and is often prominent in children under five years of age. However, the etiology of this condition has not been fully understood yet. The search in the extensive literature of peer-reviewed articles published from the inception to December 2021 was conducted to identify the relevant studies, using the electronic databases of MEDLINE/PubMed, Embase, Scopus, the Cochrane Library, and the Web of Science. The analysis of complex relationships indicates that inflammatory factors, such as various cytokines and acute-phase proteins (APPs), play leading roles in the pathogenesis of this disease. Accordingly, this article summarizes the current state of knowledge to explain the mechanisms involved in inflammatory responses among patients with PFAPA syndrome and investigate its role in the pathogenesis of this disease. Moreover, the possibilities for further implementation of new therapeutic strategies are pointed out. It is concluded that some pathophysiological processes are associated with immune dysregulation, which itself may be secondary to environmental factors, genetic background, and underlying diseases, including latent infections that multiply inflammatory mediators. elevated inflammatory markers similarly play a significant part in the clinical outcomes of this condition, whose pyrogenic nature is the reason for the development of episodes of febrile attacks in the population of patients suffering from PFAPA syndrome.

P053 The place of ASLOs in the diagnosis of RAA in Morocco

Abstract Background The assay of antistreptolysin O antibodies “ASLO” can provide evidence of infection of streptococcal origin, but it cannot confirm the presence of rheumatic fever “RAA” or the degree of severity of the disease. However, it is widely prescribed in daily practice by pediatricians and general practitioners to diagnose RAA. Unfortunately, the only finding of a high rate of ASLO in front of recurrent tonsillitis in children is considered by some practitioners as sufficient evidence to support the diagnosis of RAA, especially in its minor form, without taking into account the Jones criteria. The objective of this study is to put the ASLO assay in its place in the diagnosis of RAA in children in the region of Fez in Morocco. Methods This is a prospective study carried out from January 2016 to July 2019 in the cardiopediatric unit of CHU Hassan II in Fez. Patients below 18 years of age were included in this study. The children are classified into 4 groups: group 1: RAA with cardiac involvement, group 2: RAA without cardiac involvement, group 3: recurrent pharyngitis and group 4: control. Children with RAA are diagnosed according to the modified Jones criteria. The repetitive angina group includes any child who has tonsillitis >5 times a year. The control group presents healthy children. The ASLO assay was carried out in the central analysis laboratory of the CHU Hassan II in Fez. Patient data is collected on operating sheets. Statistical analysis was performed using SPSS v 21 software. Results These are 153 children with RAA: 119 cases of RAA with cardiac involvement and 34 cases of RAA without cardiac involvement, 86 children with recurrent pharyngitis and 157 children controls. The most common age group in the four groups is the age group between 5 and 15 years old. The frequency of children of urban origin is greater than that of rural origin in all the groups studied. The average ASLO rates in each group are as follows: RAA with carditis: 281.1 IU/ml RAA without carditis: 331.9 IU/ml Repeated angina: 397.7 IU/ml Control: 208.8 IU/ml Monitoring the change in ASLO, every 3 months for a year, in the groups studied showed that the ASLO level is stable at high rates in the case of recurrent pharyngitis and it tends to decrease in the case of AAR. Regarding the relationship between ASLO means and gender, there is a high ASLO mean in boys more than girls in all groups. Also, the mean ASLO is high in children from urban areas for the recurrent angina group. In addition, the average rate of ASLO is high during cold seasons in all groups. Finally, our study shows that the increase in ASLO is related to age. There is a significant difference between ASLO rates and age in all groups. Conclusion ASLO levels do not correlate with cardiac involvement but rather with infection and the child's individual immunity. The evidence is that ASLO levels> 200 IU/ml are more common with recurrent pharyngitis than with rheumatic heart disease. So a high ASLO is not necessarily related to an RAA. Keywords ASLO, children, RAA, recurrent tonsillitis

P055 Title: Standard rate of ASLO in healthy children with streptococcal (angina) or post-streptococcal (RAA) infection in Morocco

Abstract Background The antistreptolysins O “ASLO” are anti streptococcal antibodies directed against streptolysin O. The assay of ASLO can provide proof of infection of streptococcal origin. However, it cannot confirm the presence of RAA or the degree of severity of the disease. A level of ASLO less than or equal to a critical threshold of 200 IU/ml is considered normal in children. Several factors influence the ASLO title and therefore their standard rate such as age, geographic location and seasonal variation. The objective of this study is to determine the upper normal limit (ULN) of ASLO in healthy children with angina or RAA at the CHU Hassan II of Fez in Morocco. Methods This is a cross-sectional study carried out from January 2016 to July 2019 in the cardiopediatric unit of CHU Hassan II and the Anarjiss health center in Fez. Patients below 18 years of age were included in this study. The children are classified into 3 groups: group 1: 152 children with RAA and who are diagnosed according to the modified Jones criteria, group 2: 177 children with angina, group 3: 157 healthy children who did not have an RAA, a history of recurrent or recent pharyngitis. Patient data is collected on operating sheets. Statistical analysis was performed using SPSS v 21 software. To establish a normal upper limit for ASLOs, the 90 percentile was used as it is a value below which at least 90% of cases studied in each group. Results The most common age group in the 3 groups is the age group between 5 and 15 years old. The frequency of children of urban origin is greater than that of rural origin in all the groups studied. The ULN is 421.4U/ml in the group of normal children, 641.95 U/ml in the RAA group and 561.8 U/ml in the group of children with pharyngitis. The study of changes in ASLO rates over time shows that they increase significantly in angina and tend to decrease in RAA. The LSN of ASLOs by gender shows that it is higher for boys than for girls. The ULN according to the residence shows that it is higher in urban areas. As well as the LSN of ASLO according to the season shows that it is higher in the cold period, especially in winter and spring (P < 0.001). With regard to age, the ULN of ASLOs is higher in the 5–15 age group. Conclusion In this study, it can be concluded that an ASLO level less than or equal to 400 U/ml is the critical threshold in a normal child, while an ASLO level >400 U/ml is considered pathological in children. children in Morocco.

Additive rates model for recurrent event data with intermittently observed time-dependent covariates.

Various regression methods have been proposed for analyzing recurrent event data. Among them, the semiparametric additive rates model is particularly appealing because the regression coefficients quantify the absolute difference in the occurrence rate of the recurrent events between different groups. Estimation of the additive rates model requires the values of time-dependent covariates being observed throughout the entire follow-up period. In practice, however, the time-dependent covariates are usually only measured at intermittent follow-up visits. In this paper, we propose to kernel smooth functions involving time-dependent covariates across subjects in the estimating function, as opposed to imputing individual covariate trajectories. Simulation studies show that the proposed method outperforms simple imputation methods. The proposed method is illustrated with data from an epidemiologic study of the effect of streptococcal infections on recurrent pharyngitis episodes.

Case 292.

History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed (Figs 1, 2).

Adult-onset still's disease masquerading as hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematological condition caused by the overactivation of macrophages leading to widespread tissue destruction and organ dysfunction. The disease has a clinical overlap with adult-onset still's disease (AOSD) and hence poses a diagnostic challenge. We report the case of a 20-year-old female who presented with prolonged febrile illness, anemia, hepatosplenomegaly, and generalized lymphadenopathy. She was diagnosed with HLH and was readmitted 6 weeks later with recurrent fever, polyarthralgia, and pharyngitis. A diagnosis of AOSD with secondary HLH was made.

P403 PREVALENCE OF PREVIOUS TONSILLECTOMY IN PEDIATRIC PATIENTS WITH EOSINOPHILIC ESOPHAGITIS

Many patients with EoE are seen in ENT offices for associated otolaryngologic symptoms. We hypothesized that the prevalence of previous tonsillectomy is higher among children with EoE than those without EoE, that the most common indication for tonsillectomy is tonsillar hypertrophy and/or obstructive sleep apnea (OSA) rather than recurrent pharyngitis, and that the majority of tonsillectomies are performed prior to EoE diagnosis.

Feasibility of Powered Intracapsular Tonsillectomy in Pediatric Patients with Tonsil Problem, Including Recurrent Tonsillitis: A Single Surgeon’s Experience

Introduction: Powered intracapsular tonsillectomy (PIT) is a technique that protects the tonsillar capsule by using a microdebrider, resulting in faster wound-healing and reduced suffering. Many studies have found PIT to be effective, particularly in pediatric patients with obstructive sleep apnea (OSA). However, previous studies have not included patients with a history of recurrent tonsillitis. Objective: The aim of this study was to determine the efficacy of PIT in pediatric patients even with a history of recurrent tonsillitis, and therefore, we want to expand the indication for PIT and reveal its safety. Methods: A total of 886 pediatric patients underwent PIT between February 2013 and March 2016. All patients rated their postoperative pain using a visual analog scale (VAS) and completed the Korean obstructive sleep apnea (KOSA)-18 questionnaire for assessment of their quality of life (QOL). There were 539 males and 347 females. Their mean age was 6.2 years (range 2–14 years). The majority (77.7%) underwent the operation for OSA, and the rest (22.3%) had a history of recurrent tonsillitis. To compare the efficacy of PIT with traditional tonsillectomy, we selected 191 patients who underwent extracapsular tonsillectomy (ECT), a conventional technique, during the same time period. The median follow-up period was 16.7 months. During the follow-up period, instances of delayed bleeding and recurrent pharyngitis were monitored. Results: In comparison to the patients who underwent ECT, the PIT group showed significantly fewer cases of postoperative bleeding (p = 0.027). Thirteen patients in the PIT group (1.5%) visited the hospital during the follow-up period for pharyngitis, while 8 in the ECT group (4.2%) visited for pharyngitis. The mean postoperative pain score, as assessed by a VAS, was 4.6 ± 3.2, and pain improved within an average of 2.9 days after surgery in the PIT group. The mean KOSA-18 score for the QOL of the patients was 65.9 preoperatively and 35.6 postoperatively in the PIT group. Conclusions: Pediatric tonsillectomy using PIT is valid for reducing postoperative pain and improving the QOL of OSA patients. PIT is also effective and safe for patients with a history of recurrent tonsillitis.

Probiotic Supplementation with S. salivarius K12 in Healthy Adults Increases Oral S. salivarius K12 in a Randomized, Double-Blind, Placebo-Controlled Study

Abstract Objectives Streptococcus salivarius (S. salivarius) K12 supplementation in children and adults has been found to reduce the risk of recurrent pharyngitis, tonsillitis, otitis media caused by group A streptococci. The protection of S. salivarius K12 supplementation may in part result from its production of lantibiotic bacteriocins salivaricin A and B. Yet, studies have not reported the effect of supplementation on oral S. salivarius K12 levels or the broader salivary microbiome. The objective of this clinical trial was to determine how supplementation with S. salivarius K12 influences the oral microbiome. Methods In a double-blind, placebo-control, prospective trial, 24 healthy adults were randomized to consume a probiotic powder (PRO) containing 7.8B CFU of L. acidophilus, 8.25B CFU of B. lactis, and 2B CFU of S. salivarius K12 (n = 12) or a placebo-control powder (CON) (n = 12) for fourteen consecutive days. Saliva samples were collected at baseline, at the end of the fourteen-day supplementation period and two weeks post-supplementation. Oral S. salivarius K12 and total bacteria were quantified by QPCR and the oral microbiome was measured using 16s rRNA amplicon sequencing. Results Supplementation with S. salivarius K12 significantly increased salivary S. salivarius K12 by 5 logs compared to baseline for the PRO group (P < 0.0005) and returned to baseline 2-weeks post-supplementation. Compared with the CON group, salivary S. salivarius K12 was 5 logs higher in the PRO group at the end of the supplementation period (P < 0.001). Neither time nor supplementation influenced the oral microbiome. The supplement was well-tolerated. Conclusions Supplementation with a probiotic containing S. salivarius K12 for two weeks significantly increased levels of salivary S. salivarius K12 by 5 logs but had no effect on the overall oral microbiome measured by 16s rRNA amplicon sequencing. Funding Sources Renew Life funded this research but had no part in the analysis or interpretations of the study findings.

Value of colchicine as treatment for recurrent oral ulcers: A systematic review.

In oral medicine, colchicine is a therapeutic alternative for idiopathic recurrent aphthous stomatitis (RAS), Behçet disease (BD), periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome, and mouth and genitals ulcers with inflamed cartilage (MAGIC) syndrome. The present review aims to evaluate reliability of colchicine against recurrent oral ulcers. A systematic review was conducted, with the following PICO (Patient, Intervention, Control, Outcome) question: "In populations with idiopathic or secondary recurrent oral ulcers, is colchicine more effective in improving pain and accelerating healing, compared to other intervention or placebo?" Seven RCTs and 3 OCTs were considered eligible. Four RCTs focused on BD, two RCTs and three OCTs on RAS, and one RCT on PFAPA syndrome. Heterogeneity between RCTs prevented from meta-analysis. Regarding BD, no significant difference between colchicine and placebo was found in two of three placebo-controlled RCTs, whereas the third RCT showed benefit. A comparative RCT found ciclosporin more effective than colchicine for oral lesions of BD. One open-label RCT showed promising but partial results on colchicine in reducing PFAPA attacks, when compared to corticosteroids. Concerning RAS, colchicine appeared less effective than clofazimine, thalidomide and dapsone, and with outcomes similar to low-dosage corticosteroids but higher gastric discomfort than prednisolone. One OCT reported positive results compared with no treatment but a RCT found no difference with placebo. Role of colchicine as treatment for idiopathic or secondary recurrent oral ulcers is still controversial. Further standardized RCTs and crossover trials are needed.

Tonsillotomy versus Tonsillectomy for Chronic Recurrent Tonsillitis in Children.

This study was conducted to compare two different surgical methods; partial tonsil resection using the bipolar technique, tonsillotomy (TT), and total tonsillectomy (TE) (blunt dissection) for recurrent tonsillitis in children. The frequency of recurrent throat infections was determined during postoperative follow-up. A total of 393 patients were included in this study. TT was performed on 174 patients (100 males, 74 females) and TE on 219 patients (112 males, 107 females). Following surgery, an analysis was made of treatment outcomes of patients with upper respiratory tract infections. The patients were followed up for 12-48 months. Their parents were also contacted by telephone to determine the frequency of reinfection and their satisfaction with the surgery. Also, parents of the patients completed a questionnaire pertaining to postoperative satisfaction (scale of 1-10). In the TT group, 14 (8.1%) patients had recurrent tonsillitis postoperatively. In the TE group, 12 (5.4%) patients required antibiotherapy due to recurrent pharyngitis after the surgery. There was no significant difference between the two groups in terms of the one-year infection recurrence rate after surgery (p=0.281). Three patients (1.6%) in the TT group and 12 (5.4%) in the TE group complained of bleeding within the first 24 hours. The rate of bleeding was significantly lower in the TT group than the TE group (p=0.001). There were no fatalities in either group. In both groups, the rate of reinfection accorded with the requirement for postoperative antibiotics. For recurrent tonsillitis, TT was as effective as TE. However, TT was superior in terms of the risk of bleeding.

Tonsillectomy for periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome (PFAPA).

Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome is a rare clinical syndrome of unknown cause usually identified in children. Tonsillectomy is considered a potential treatment option for this syndrome. This is an update of a Cochrane Review first published in 2010 and previously updated in 2014. To assess the effectiveness and safety of tonsillectomy (with or without adenoidectomy) compared with non-surgical treatment in the management of children with PFAPA. The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2019, Issue 4); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 15 October 2019. Randomised controlled trials comparing tonsillectomy (with or without adenoidectomy) with non-surgical treatment in children with PFAPA. We used the standard methodological procedures expected by Cochrane. The primary outcomes were the proportion of children whose symptoms have completely resolved and complications of surgery (haemorrhage and number of days of postoperative pain). Secondary outcomes were: number of episodes of fever and the associated symptoms; severity of episodes; use of corticosteroids; absence or time off school; quality of life. We used GRADE to assess the certainty of the evidence for each outcome. Two trials were included with a total of 67 children randomised (65 analysed); we judged both to be at low risk of bias. One trial of 39 participants recruited children with PFAPA syndrome diagnosed according to rigid, standard criteria. The trial compared adenotonsillectomy to watchful waiting and followed up patients for 18 months. A smaller trial of 28 children applied less stringent criteria for diagnosing PFAPA and probably also included participants with alternative types of recurrent pharyngitis. This trial compared tonsillectomy alone to no treatment and followed up patients for six months. Combining the trial results suggests that patients with PFAPA likely experience less fever and less severe episodes after surgery compared to those receiving no surgery. The risk ratio (RR) for immediate resolution of symptoms after surgery that persisted until the end of follow-up was 4.38 (95% confidence interval (CI) 0.64 to 30.11); number needed to treat to benefit (NNTB) = 2, calculated based on an estimate that 156 in 1000 untreated children have a resolution) (moderate-certainty evidence). Both trials reported that there were no complications of surgery. However, the numbers of patients randomly allocated to surgery (19 and 14 patients respectively) were too small to detect potentially important complications such as haemorrhage. Surgery probably results in a large overall reduction in the average number of episodes over the total length of follow-up (rate ratio 0.08, 95% CI 0.05 to 0.13), reducing the average frequency of PFAPA episodes from one every two months to slightly less than one every two years (moderate-certainty evidence). Surgery also likely reduces severity, as indicated by the length of PFAPA symptoms during these episodes. One study reported that the average number of days per PFAPA episode was 1.7 days after receiving surgery, compared to 3.5 days in the control group (moderate-certainty evidence). The evidence suggests that the proportion of patients requiring corticosteroids was also lower in the surgery group compared to those receiving no surgery (RR 0.58, 95% CI 0.37 to 0.92) (low-certainty evidence). Other outcomes such as absence from school and quality of life were not measured or reported. The evidence for the effectiveness of tonsillectomy in children with PFAPA syndrome is derived from two small randomised controlled trials. These trials reported significant beneficial effects of surgery compared to no surgery on immediate and complete symptom resolution (NNTB = 2) and a substantial reduction in the frequency and severity (length of episode) of any further symptoms experienced. However, the evidence is of moderate certainty (further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate) due to the relatively small sample sizes of the studies and some concerns about the applicability of the results. Therefore, the parents and carers of children with PFAPA syndrome must weigh the risks and consequences of surgery against the alternative of using medications. It is well established that children with PFAPA syndrome recover spontaneously and medication can be administered to try and reduce the severity of individual episodes. It is uncertain whether adenoidectomy combined with tonsillectomy adds any additional benefit to tonsillectomy alone.

Immune Dysregulation in the Tonsillar Microenvironment of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) Syndrome.

Periodic Fever, Aphthous stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome is an inflammatory disorder of childhood classically characterized by recurrent fevers, pharyngitis, stomatitis, cervical adenitis, and leukocytosis. While the mechanism is unclear, previous studies have shown that tonsillectomy can be a therapeutic option with improvement in quality of life in many patients with PFAPA, but the mechanisms behind surgical success remain unknown. In addition, long-term clinical follow-up is lacking. In our tertiary care center cohort, 62 patients with PFAPA syndrome had complete resolution of symptoms after surgery (95.3%). Flow cytometric evaluation demonstrates an inflammatory cell population, distinct from patients with infectious pharyngitis, with increased numbers of CD8+ T cells (5.9% vs. 3.8%, p < 0.01), CD19+ B cells (51% vs. 35%, p < 0.05), and CD19+CD20+CD27+CD38-memory B cells (14% vs. 7.7%, p < 0.01). Cells are primed at baseline with increased percentage of IL-1β positive cells compared to control tonsil-derived cells, which require exogenous LPS stimulation. Gene expression analysis demonstrates a fivefold upregulation in IL1RN and TNF expression in whole tonsil compared to control tonsils, with persistent activation of the NF-κB signaling pathway, and differential microbial signatures, even in the afebrile period. Our data indicates that PFAPA patient tonsils have localized, persistent inflammation, in the absence of clinical symptoms, which may explain the success of tonsillectomy as an effective surgical treatment option. The differential expression of several genes and microbial signatures suggests the potential for a diagnostic biomarker for PFAPA syndrome.

853. Epidemiology of Groups A, C, and G β-Hemolytic Streptococcal Pharyngitis

BackgroundTreatment of Group A Streptococcus (GAS) pharyngitis is imperative to mitigate sequelae such as rheumatic heart disease. The need for treatment of Group C Streptococcus (GCS) and Group G Streptococcus (GGS) pharyngitis is unclear, as rheumatogenic sequelae have not been well documented. Our institution switched from culture to molecular confirmation testing for a negative rapid streptococcal antigen detection test. Cultures reported GAS whereas molecular testing reported GAS, GCS, and GGS. We performed a retrospective chart review to examine the epidemiological differences of GAS, GCS, and GGS pharyngitis.MethodsRecords were obtained of pharyngeal samples from patients sent for testing at Beaumont Health Laboratory. In all, 92,369 records were analyzed. There were 47,106 records of cultures from May 2012 through December 2014 and 45,263 records of molecular testing from May 2015 to December 2017. Samples positive for either GCS or GGS were reported as positive for Group CG Streptococcus (GCGS). Epidemiological factors were evaluated. If available, electronic records from GCGS positive samples were evaluated for clinical features, antibiotics used, and sequelae or complications reported.ResultsMolecular testing showed GAS positivity of 9.3% (n = 4,189) and GCGS positivity of 1.5% (n = 687). GCGS pharyngitis was more likely during the summer months and in young adults 13 years and older than children under 13 years. GAS pharyngitis was more likely during spring months and in children aged 4–9 years. Mean age of GCGS pharyngitis was 13 vs. 8.6 years for GAS pharyngitis. Similar results were obtained for GAS between culture and molecular testing records. Amoxicillin was most often prescribed for treatment of GCGS. There were few instances of severe GCGS exudative or recurrent pharyngitis that required hospitalization or tonsillectomy. There were no cases of rheumatic fever or rheumatic heart disease associated with GCGS.ConclusionThis is the largest study based on our literature review to evaluate the epidemiology of GAS, GCS, and GGS pharyngitis in children and adults. We found a seasonal and age difference between GAS and GCGS. Complications were rare, and no rheumatogenic sequelae were noted from GCGS infections. Disclosures All Authors: No reported Disclosures.