Tonsillar Exudate Research Articles

The relationship between group A streptococcus test positivity and clinical findings in tonsillopharyngitis in children: systematic review and meta-analysis.

This study aimed to present an evidence-based conclusion through a systematic meta-analysis to distinguish clinical signs and symptoms associated with the presence of group A beta-hemolytic streptococcus, as confirmed by throat culture or rapid test, from those in cases without culture confirmation. The study protocol has been published in PROSPERO (CRD42023450854). Studies published between January 1, 2013 and August 15, 2023 were scanned in seven databases. The methodological quality of the articles was assessed using The Joanna Briggs Institution (JBI) Cross-Sectional Studies and Cohort Studies checklist. Effect size calculations were made using fixed effects and random effects models. A total of 22 articles were included in the systematic review, with 14 included in the meta-analysis. The prevalence of streptococcal pharyngitis in these studies ranged from 7.3 to 44.1%. According to the meta-analysis results, a significant association was observed between GAS test positivity and the presence of tonsillar exudate, palatal petechiae, tonsillar hypertrophy, dysphagia, fever, and cervical lymphadenopathy (p < 0.05). No significant relationship was found between GAS test positivity and symptoms such as headache, sore throat, cough, absence of cough, hoarseness, scarlatiniform rash, tonsillar erythema, vomiting, rhinorrhea, and abdominal pain (p > 0.05). The findings of the meta-analysis suggest that, in addition to the Centor criteria, palatal petechiae, dysphagia, and tonsillar hypertrophy are noteworthy indicators of GAS infection. Contrary to previous studies, our meta-analysis indicates that symptoms such as headache, sore throat, cough, absence of cough, hoarseness, scarlatiniform rash, tonsillar erythema, vomiting, rhinorrhea, and abdominal pain may not be associated with streptococcal infection. Further research is needed to elucidate these findings.

Group A Streptococcus infections in children and adolescents in the post-COVID-19 era: a regional Italian survey

BackgroundDespite the worldwide increasing incidence of Group A Streptococcus (GAS) infections reported since December 2022, data on noninvasive GAS (nGAS) infections in the post COVID-19 era are limited. By a self-reported survey performed in an outpatient setting, we investigated the number and clinical features of GAS infections, the diagnostic work-up and the type of treatment utilized. In addition, the rate of influenza vaccination was evaluated.MethodsIn June 2023 family pediatricians involved in the study sent the survey to parents of patients aged 0–16 years. The survey included questions on GAS infections that occurred from January 1 to May 31, 2023.ResultsAmong 3580 children, 20.3% had a GAS infection (0,8% < 1 year, 16,4% 1–3 years, 42,3% 3–6 years, 26,5% 6–9 years, 11,4%, 9–12 years, and 2,6% 12–16 years). Symptoms reported were sore throat (76.9%), fever (75.2%), tonsillar exudate (25.2%), lymphadenopathy (21.8%), and scarlet fever (14.7%). A single patient was hospitalized due to GAS meningitis.Twenty four percent of children had more than one GAS infection. In this group, frequencies of symptoms reported in the first and in the following infection were similar, except for fever and scarlet fever which were less frequent during relapses. GAS was identified by rapid antigen detection test in 81.0% of children. Eighty-nine per cent of children were treated with antibiotics, mostly amoxicillin/clavulanate (40.4%) and amoxicillin (39.4%). Thirty four percent of children received influenza vaccine. No difference was observed among immunized and not immunized regarding the number and characteristics of GAS infection. ConclusionsWe reported a certain prevalence of nGAS infections in children, mainly those aged 3–6 years age, who were mostly characterized by a low score of symptoms, and in most of the cases diagnosed and treated using a microbiological test as confirmatory tool.In this new clinical setting, a national study would be useful to reach more significant data for the definition of a correct diagnosis and clinical management of nGAS infections in children. Moreover, it is important to improve flu vaccination campaign and coverage to protect children from coinfections that could worsen the disease and misdiagnose the etiology of pharyngitis.

Detection of positive test for Trichomonas vaginalis in oropharyngeal exudate from а patient with pharyngitis by amplification of nucleic acids: clinical case

Trichomoniasis is the most common infectious and inflammatory disease that is mainly sexually transmitted. Trichomonads are a group of flagellated protozoa. Four species of them infect humans: Trichomonas vaginalis, Trichomonas tenax, Dientamoeba fragilis and Pentatrichomonas hominis. Among them, only Trichomonas vaginalis is considered pathogenic, while the pathogenicity of other species is debatable. According to the WHO, more than 180 million cases of urogenital trichomoniasis are reported annually. Epidemiology of urogenital trichomoniasis has not been studied enough, but the prevalence of this infection, unlike gonorrhea and urogenital chlamydia, increases in older age groups. In women with pelvic inflammatory disease, trichomonas are detected in 5.6—20.6 % of cases, in pregnant women — in 0.98—32 %, in patients with infertility — in 19.5 %, in men with inflammatory genital diseases — in 0.2—8.5 % of cases. The only reliable evidence of trichomonas etiology of the lesion is laboratory detection of the pathogen in biological materials.We describe a clinical case of a patient K., aged 29 years, with symptoms of pharyngitis, in whom urogenital trichomonads were detected in the pharyngeal and tonsillar exudate by polymerase chain reaction. During a thorough anamnesis, patient K. reported her participation in unprotected oral sex with a partner who had been diagnosed with urogenital trichomoniasis. In view of the above, patient K. was offered an oropharyngeal exudate test for sexually transmitted infections. Pharyngeal and tonsillar exudate obtained with the ThinPrep Non Gyn non-gynecological test gave a positive result for Trichomonas vaginalis using the nucleic acid amplification test. Test results for HIV, syphilis, tuberculosis, chlamydia and gonorrhea were negative. The results of the culture testing for opportunistic pathogens were also negative. The oropharyngeal swab with nucleic acid amplification test was positive for Trichomonas vaginalis. Conclusions. Careful collection of the anamnesis of sexual life and examination of swabs from the oropharynx with the help of nucleic acid amplification test made it possible to detect Trichomonas vaginalis in the oral cavity. The patient and her sexual partner were successfully treated. This case indicates that Trichomonas vaginalis can be transmitted orally after unprotected oral sex with a partner who has been diagnosed with urogenital trichomoniasis.Given that the clinical case presented by us and the results of the diagnostic tests are not consistent with the existing recommendations of the Center for Disease Control and Prevention, further clinical and laboratory studies are advisable to determine the possibility of oral transmission of Trichomonas vaginalis during unprotected oral sex, as well as the likelihood of these pathogenic unicellular parasites being involved in the development/maintenance of inflammatory processes of the oropharyngeal mucosa.

Prevalence, Antibiotic Susceptibility Pattern and Associated Factors of Streptococcus pyogenes among Pediatric Patients with Acute Pharyngitis in Sidama, Southern Ethiopia

Background. Streptococcus pyogenes is the most frequent cause of pharyngitis and skin infections in children and causes immune complications like rheumatic fever and rheumatoid heart disease (RHD), particularly in developing countries like Ethiopia. The aim of this study was to determine the prevalence, antibiotic resistance pattern, and associated factors of Streptococcus pyogenes among pediatric patients suspected of acute pharyngitis in Sidama Region, Southern Ethiopia. Methods. A cross‐sectional study was conducted on 213 acute pharyngitis suspected pediatric patients from April to September 2022 at Hawassa University Compressive Specialized Hospital and Yirgalem Hospital. Sociodemographic and clinical data were collected using a structured questionnaire. A throat swab was cultured to isolate S. pyogenes, and antimicrobial susceptibility testing was done using standard bacteriological techniques. Data were analyzed using SPSS version 25, and P value of &lt;0.05 was considered as statistically significant. Result. Out of 213 throat swabs cultured, 22 (10.3%) with 95% CI (6.6–14.6%) were S. pyogenes positive. All isolates of S. pyogenes were sensitive to penicillin and amoxicillin. In contrast, 8 (36.4%) isolates exhibited resistance to tetracycline, 7 (31.8%) to ceftriaxone, 6 (27.3%) to erythromycin, and 5 (22.7%) isolates showed multidrug resistance. The presence of palatal petechiae (P = 0.037) and tonsillar swelling or exudate (P = 0.007) were significantly associated with S. pyogenes carriage in children suspected of having acute pharyngitis. Conclusion. In this study, the prevalence of S. pyogenes among children suspected with acute pharyngitis was low compared to other studies. The isolates showed a high level of resistance to commonly used antibiotics. Therefore, the treatment of pediatric acute S. pyogenes pharyngitis should depend on an antimicrobial susceptibility test. Furthermore, evaluation of S. pyogenes pediatric acute pharyngitis risk factors and tracking of antibiotic resistance are crucial in the controlling of pediatric acute S. pyogenes pharyngitis.

A High Copy Number from a Pharyngeal Swab Is Not Associated with Different Presenting Features in 100 Children with Acute Adenovirus Infection from a Cluster in Italy.

Human mastadenoviruses, frequently denominated adenoviruses (HAdVs), may cause respiratory tract, gastrointestinal or, less frequently, other involvements. Epidemics of HAdV infections occur globally, in communities, and in closed or crowded settings. In our institution, a cluster of infants and children admitted for HAdV infection was recently observed. The aim of this study was to describe the pattern of their presenting features and investigate the possible correlation between the HAdV copy number and the clinical picture. Two main patterns of clinical presentation were observed: 68 patients had mainly respiratory symptoms (pharyngitis n = 67, cough n = 44; tonsillar exudate n = 17; other respiratory signs n = 4) while 26 patients showed prevalent gastrointestinal involvement (diarrhea n = 26, vomiting n = 8). Patients with respiratory symptoms had a significantly higher count of WBC, PMN, and platelets, while CRP level approached statistical significance (p = 0.07) for higher values in the patients with diarrhea. In order to explore the impact of selected presenting features, the possible association between the level of CRP and the presence of pharyngeal exudate, cough, vomiting, diarrhea, duration of fever, number of neutrophils, and administration of antibiotics was analyzed. Patients falling in the tertile with more elevated CRP values had tonsillar exudate and diarrhea significantly more often, while those in the lower tertile had a 4.4-day duration fever vs. ≥5.0 days in the remaining patients. Antibiotic therapy was administered more frequently to patients with higher values of CRP (p = 0.006). The duration of hospitalization was not associated with the CRP level. The median time from the receipt of a positive HAdV PCR test result to patient discharge was 1 day in 73% of cases. The number of copies of HAdV detected via PCR ranged between 47 million and 15/μL. Falling in the highest tertile of copy number was significantly associated with pharyngitis. The 24 patients with evidence of viral coinfection had no difference in the demographics or presenting features, with the only exception being a significantly higher leukocyte count. The rapid turn-around of the results of the molecular testing of the HAdV genome on a pharyngeal swab allowed us to rapidly diagnose HAdV infection, allowing us to stop antibiotic therapy and immediately discharge the patients, with reduced discomfort for the families and more appropriate use of hospital beds. A high copy number of HAdV from a pharyngeal swab should not be taken as an indicator of worse prognosis, thus allowing for the preferential use of qualitative rather than quantitative assay.

Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department

BackgroundRight upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. Case ReportThis case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. Why Should an Emergency Physician Be Aware of This?Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.

Antibiotic-Prescribing Patterns Among Patients With Respiratory Symptoms in the Eastern Province, Kingdom of Saudi Arabia.

Background Upper respiratory tract infections (URTIs) represent the most common diagnosis in ambulatory care settings. Some of these infections are properly treated with antibiotics, but evidence points to an inappropriate overuse of antibiotics in URTI management. This overuse is linked to antibiotic resistance, drug-related adverse effects, and increased costs. Objective This study evaluated the prevalence and predictors of antibiotic prescription for patients with URTI symptoms at the primary healthcare centers (PHCCs) and pediatric emergency department (ED) of the Maternity and Children Hospital (MCH) in Dammam, Saudi Arabia. Methods A prospective study was conducted in the PHCCs and pediatric ED of MCH. Trained physicians collected data on patients with URTI symptoms aged three years and older. Scores based on modified Centor criteria were calculated, and rapid antigen detection tests(RADTs) were conducted for all study participants. Results Out of 469 patients with a URTI, 141 (30.1%) received a prescription for an antibiotic, with a smaller proportion in the PHCCs (n=85; 24.4%) than in the pediatric ED (n=56; 46.3%). The main significant predictors of antibiotic prescription in terms of odds ratio (OR) and 95% confidence interval (95%CI) were a positive RADT result (OR=41.75, 95%CI=4.76-366.28), the presence of tonsillar exudate (OR=5.066, 95%CI=3.08-8.33), tender and/or swollen anterior cervical lymph nodes (OR=4.537, 95%CI=1.96-10.54), and fever (OR=3.519, 95%CI=2.33-5.31). A higher Centor score was also a predictor (2 to 5 vs. -1 to 1) (OR=2.72, 95%CI=1.8-4.12). The absence of a cough was not a significant predictor (OR=1.13, 95%CI=0.74-1.72). Conclusions Although a positive RADT increased the likelihood that a patient would be prescribed an antibiotic at the time of assessment, most antibiotic prescriptions were not justified. To control expenses, prevent adverse effects, and limit the spread of antibiotic resistance, efforts should be made to reduce unnecessarily high antibiotic usage.

Isolation and Characterization of Streptococcus pyogenes from Iraqi Children with Pharyngotonsillitis

Background: Streptococcus pyogenes known as group A streptococci (GAS) is the main causative agent of pharyngotonsillitis in children younger than 12 years old. The infection appears mostly in winter and spring. Signs and symptoms of patients with a beta-hemolytic GAS infection, include tonsillar exudate, fever, painful anterior cervical adenopathy, and the lack of a cough. Penicillin and ampicillin are the preferred clinical therapy choice for GAS pharyngitis treatment. Objectives: Isolate and identify GAS in throat swabs among children suffering from acute pharyngotonsillitis to estimate the prevalence rate of bacterial isolates associated with age, sex, and months variation of GAS infection. Also, it is to determine the antibiotic sensitivity patterns such as penicillin, ampicillin, erythromycin, azithromycin, ofloxacin, clindamycin, and rifampicin, which are used for the treatment of GAS associated with the acute pharyngotonsillitis in children. Materials and Methods: Four hundred and ten throat swabs have been obtained from patients who were clinically diagnosed as having acute pharyngotonsillitis of age ranging from (1–12) years of both sexes were admitted to various hospitals and enrolled in a sequential manner from November 2021 to April 2022 in two Governorates (Baghdad and Babylon), Iraq. These throat swabs were exposed to the bacterial culturing, and some other tests. Streptococcus pyogenes isolates were identified depending on the colony properties, beta-hemolysis on sheep blood agar plate, Gram’s stain, catalase production test, in addition to a sensitivity to bacitracin and Pyrrolidinyl arylamidase test to confirm the identification of GAS. Results: The prevalence of identifying GAS isolates was 140 (34.1%) out of 410 samples. GAS strains can cause acute pharyngotonsillitis in children of all ages, but it most frequently occurred between 1 and 6 year age groups, and it was more in men 80 (57.1%) than in women 60 (42.9%). Likewise, it was found that GAS associated with acute pharyngotonsillitis with a high incidence in winter and in early spring, in which the peak of GAS infection has been seen in January (30.7%). On the other hand, some antibiotics were used to show their effect on these GAS isolates. The findings revealed that all isolates were sensitive (100%) to penicillin and ampicillin, and (83.6%) of isolates were sensitive to clindamycin, whereas some isolates shown a lesser degree of sensitivity (75% and 60%) to rifampicin and ofloxacin. However, only 49.3% of the isolates were sensitive to erythromycin, and (46.4%) were sensitive to azithromycin. Conclusion: GAS strains can cause acute pharyngotonsillitis in children of all ages, but it most frequently occurred in the age groups (1–6) year, and more predominant in men than in women. High percentage of infections with GAS have been noticed in winter and spring to reach its peak in January. Additionally, penicillin and ampicillin are preferred antibiotic for treatment, whereas in the most serious cases clindamycin was added to the treatment plan.

Association Between Vitamin D Deficiency and Recurrent Tonsillitis.

Tonsillitis is defined as an inflammation of the tonsils characterized by signs of tonsillar erythema and exudates and recurrent tonsillitis is at least 7 episodes of acute tonsillitis in a year, or a minimum of 5 episodes in a year for 2 consecutive years, or at least 3 episodes in a year for 3 consecutive years. There are many research that have hypothesized the association of low level of Vitamin D and recurrent attacks of acute tonsillitis. A single centre prospective, cross sectional analytical study was conducted from 2021 June to 2022 March in Department of ENT and Head and Neck surgery in Kathmandu Medical College Teaching Hospital. The study participants were recruited from ENT Head and Neck OPD and the data on number of episodes of recurrent attacks of tonsillitis and serum level of Vitamin D were collected. 78.8% of patients with tonsillitis had low level of serum Vitamin D (less than 30ng/ml) and 21.2% had optimal level of serum Vitamin D (more than 30ng/ml). The incidence of recurrent tonsillitis was 40.9% in patients with low level of Vitamin D where as the incidence of recurrent tonsillitis was 18.1% in patients with optimal level of Vitamin D. The low serum level of Vitamin D was found to be associated with recurrent episodes of tonsillitis.

Prevalence, Antibiotic Susceptibility Profile and Associated Factors of Group A Streptococcal pharyngitis Among Pediatric Patients with Acute Pharyngitis in Gondar, Northwest Ethiopia.

Streptococcus pyogenes (S. pyogenes) or group A streptococcus is a common cause of bacterial pharyngitis in children. Since it is difficult to distinguish between viral and bacterial pharyngitis using solely signs and symptoms, culture-based diagnosis and treatment are critical for avoiding serious complications. Therefore, this study aimed to determine the prevalence, antimicrobial susceptibility patterns, and associated factors of S. pyogenes among pediatric patients with acute pharyngitis. A hospital-based cross-sectional study was conducted at the University of Gondar Comprehensive Specialized Hospital from April to June 2021. Standard microbiological procedures were used to collect and process throat swabs and to isolate and identify S. pyogenes. The disc diffusion method was used for antimicrobial susceptibility testing (AST). A total of 215 children with acute pharyngitis were included in this study. Of these, 23 (10.7%) were culture positive for S. pyogenes. The presence of an inflamed tonsil, tonsillar exudate, scalariform rash, and dysphagia were associated with streptococcal pharyngitis. Children aged 5 to 15 were more susceptible to streptococcal throat infection than younger children. Penicillin, vancomycin, chloramphenicol, clindamycin, and ceftriaxone were effective against 100%, 95.7%, 95.7%, 91%, and 87% of isolates, respectively. In contrast, 56.5%, 39.1%, and 30.4% of isolates showed at least reduced susceptibility to tetracycline, erythromycin, and azithromycin, respectively. Streptococcus pyogenes is responsible for 10.7% of acute pharyngitis cases among pediatric patients in the study area. Although all isolates remain sensitive to penicillin, many showed reduced susceptibility to tetracycline and macrolides. Therefore, prior to antibiotic prescription, screening children with acute pharyngitis for S. pyogenes and testing the antibiotic susceptibility of isolates is recommended.

Recurrent Penicillin-Resistant Tonsillitis Due to Lactococcus garvieae, a New Zoonosis from Aquaculture

Zoonotic diseases are a group of infectious diseases that are transmitted naturally from animals to humans. L. garvieae is a Gram-positive bacterium which is present in the aquaculture of freshwater and marine fish. Some isolated cases of infection have been described, considering it an opportunistic agent in immunosuppressed patients. The most recent appearance of severe infections in immunocompetent patients or colonizing cardiac prostheses has set off the alarms. This manuscript presents the first two patients with recurrent tonsillitis due to L. garvieae. A 15-year-old male and an 8-year-old male had recurrent tonsillitis with more than three episodes per year. A culture of tonsillar exudate in both cases showed growth of L. garvieae with an antibiogram showing multi-resistance to antibiotics. Given the parents’ wish not to carry out surgery, an autovaccine regimen with lysed bacteria was proposed with good evolution and remission of tonsillitis episodes in both cases. The oral autovaccine produces an immunomodulatory effect and could be a therapeutic weapon in the prevention of this zoonosis. Further studies are needed to determine the importance of foodborne transmission in human L. garvieae infections and to find suitable treatments for this wide range of infections.

SINGLE CAVITARY LUNG LESION IN A HEALTHY YOUNG MALE

SINGLE CAVITARY LUNG LESION IN A HEALTHY YOUNG MALE

S2350 Mind the Steroids: Herpes Esophagitis in an Immunocompetent Patient After Steroid Therapy

Introduction: Infective esophagitis (IE) is rare, but well known to complicate the immunosuppressed state; particularly the HIV infected, transplant recipient, cancer patient and those treated with chronic corticosteroids or immunomodulators. Common infections include candida, cytomegalovirus, and herpes simplex virus (HSV). Steroids have been used for symptomatic relief of an acute sore throat. Short courses are considered benign with low risk of infectious complications. We report an immunocompetent patient found to have herpes esophagitis after a short course of corticosteroids. Case Description/Methods: A 41-year-old African American male with history of hypertension presented with worsening sore throat and odynophagia restricting oral intake. Prior to presentation, he had a 10-day history of sore throat. He was diagnosed with streptococcal pharyngitis and was on antibiotics and steroids 7 days ago. Given persistent symptoms he underwent laryngoscopy which demonstrated bilateral tonsillar exudates and normal pharyngeal mucosa, prompting admission and initiation of IV antibiotics and dexamethasone. He had modest improvement of pain, however 8 days later expressed worsening burning retrosternal chest pain and progressed oral intolerance. He underwent upper endoscopy revealing multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus (Figure A). Biopsies demonstrated viral intranuclear inclusions that stained positive for HSV1/HSV2 (Figure B, C). His symptoms abated while on IV acyclovir allowing transition to oral valacyclovir. Discussion: Corticosteroids are well known for their anti-inflammatory effect but immunosuppression with short courses may be underestimated. Infectious sequalae such as herpetic esophagitis may complicate steroid use even when therapy duration is short. This patient was found to have progressive odynophagia while on corticosteroids administered for analgesia and had significant improvement after antiviral therapy. It is easy to overlook IE as a cause of odynophagia in the immunocompetent, however, with history of steroid use, a diagnosis of IE, especially HSV esophagitis, should be considered in the differential. Therefore, one should have a low threshold for early endoscopy when evaluating these patients.Figure 1.: A: Endoscopic photograph displaying multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus. B: (x200): Photomicrograph of hematoxylin and eosin-stained section of the esophageal biopsy, showing multiple multinucleated epithelial cells. Cowdry type A is observed. C: (x200): IHC study using antibodies against HSV-1. Numerous intranuclear viral inclusions are positive with HSV-1 within the infected cells.

37-Year-Old Man With Headache and Nasal Congestion

37-Year-Old Man With Headache and Nasal Congestion

Prevalence and Clinical Presentation of Group A Streptococcal Pharyngitis in Children at a Tertiary Hospital in Gombe, North-East Nigeria

Background: Globally, Group A ß-Haemolytic Streptococcus (GAßHS) pharyngitis and its complications are major contributors to childhood morbidity and mortality, especially in developing countries. The diagnosis and treatment of GAßHS pharyngitis in these countries is often empirical resulting in frequent misdiagnosis and inappropriate treatment. Determining the local prevalence and clinical presentations of GAßHS pharyngitis will be essential for making informed clinical decision. Objective: The objective of the study was to determine the prevalence and clinical presentations of GAßHS among children with pharyngitis at a tertiary hospital in Gombe, North-eastern Nigeria. Methods: 324 children aged 3-18 years were consecutively recruited at the out-patient clinic between 1st April 2018 to 30th September 2018. Socio-demographic and clinical features were recorded and throat swab samples were cultured on 5% sheep blood agar to diagnose GAßHS.Result: The prevalence of GAßHS pharyngitis was 25.9% and was significantly higher; in females (67.1%) (p=0.046), in children aged 11-14 years (32.1%) (p= 0.008) and during peak rainfall (p=0.001). The clinical features significantly associated with GAßHS pharyngitis were; runny nose (p&lt;0.001), cough (p&lt;0.001) and sorethroat (p&lt;0.001), fever (p&lt;0.001), palatal petechiae (p&lt;0.001), pharyngeal erythema and exudates (p=0.001), tonsillar enlargement and exudates (p&lt;0.001), cervical lymph node tenderness (p=0.010), halitosis (p=0.029), and scarlet rash (p=0.001). Conclusion: GAßHS pharyngitis is prevalent in children especially during peak of rainfall and some clinical features are commoner among patients with GAßHS pharyngitis. These clinical symptoms and signs can be used to guide empiric treatment decision.

Minor salivary gland infection as origin of peritonsillitis – novel theory and preliminary results

Background Peritonsillitis (PT) is defined as cellulitis in peritonsillar tissue without pus. The pathogenesis of peritonsillar infections is controversial. Objective To explore whether minor salivary glands are involved in the development of PT and to identify clinical findings that predict the evolution of PT to peritonsillar abscess (PTA). Material and methods We included 146 adult patients treated for acute tonsillitis (AT; n = 54), PT (n = 34), or PTA (n = 58) at the Helsinki University Hospital. The treating physician recorded tonsillar, oropharyngeal, and dental findings. We analysed serum C-reactive protein (S-CRP) and amylase (S-Amyl). For PTA, pus samples were analysed; for AT and PT, throat cultures were collected. Patients with PT or PTA (PT/PTA; n = 92) were classified into groups with or without tonsillar exudate or hyperaemia (tonsillar findings). Results The PT group without tonsillar findings had lower S-CRP than the PT group with tonsillar findings (p=.0275). The PT/PTA group without tonsillar findings had higher S-Amyl than the PT/PTA group with tonsillar findings (p=.0278). Three out of 34 (8.8%) patients with PT returned to the emergency department; 1 (2.9%) developed PTA. Conclusions Elevated S-Amyl in the PT/PTA group without tonsillar findings suggests that minor salivary glands are sometimes involved in the development of peritonsillar infections.

Do not Forget the ‘Forgotten Disease’ in the Covid Era: A Case Report of Lemierre’s Disease with a Rare Complication of Acute Renal Failure

<strong>Background:</strong> Lemierre’s disease, also known as the “Forgotten disease”, is a rare yet rapidly deteriorating clinical entity associated with high morbidity and mortality. We present a unique case of acute renal failure in Lemierre’s Disease which has not been previously reported in published literature. <strong>Case report:</strong> An obese 18-year-old female with intermittent asthma presented with a one-week history of sore throat, dysphagia and odynophagia associated with anuria. She was found to be in severe sepsis with tachycardia (163 bpm), hypotension (BP 113/43) and acute renal failure with bilateral tonsillar exudates, mild anterior neck swelling and trismus. Initial labs were also significant for leukocytosis (WBC 29.4 k/ul), transaminitis (AST 1115 u/L, ALT 240 u/L), and severe rhabdomyolysis (creatine kinase 96848 u/L). She received intravenous fluids with good response and started on vancomycin and piperacillin-tazobactam. Initial infectious work-up was negative for group A streptococcus (throat), SARS-CoV-2 PCR and antibody, HIV, RPR, EBV, hepatitis A/B/C. Initial chest x-ray revealed bilateral nodular opacities with likely miliary distribution for which TB evaluation was considered but later aborted. Admitting diagnoses were severe sepsis from soft tissue infection (neck vs. pneumonia) with possible bacteremia and acute renal failure (pre-renal exacerbated by severe rhabdomyolysis). The patient’s case was complicated early on by the development of anuric renal failure (creatinine 7.5 mg/dL) and hyperkalemia for which she required hemodialysis by day 3 of hospitalization. Other complications included respiratory distress and hypoxia requiring transient BiPAP support and transiently elevated pro-BNP and troponin which all spontaneously resolved. An echocardiogram revealed borderline normal LV systolic function. A non-contrast head and neck CT showed asymmetric enlargement of the left parotid gland and palatine tonsil with no obstruction and enlargement of left internal jugular lymph nodes compatible with reactive changes. On the 4th hospital day, the initial blood culture was found to be positive forFuscobacterium necrophorum, for which metronidazole was added pending culture sensitivity results. Due to concerns for septic thromboemboli, contrast CT studies of the head, neck and chest were done revealing multiple large bilateral pulmonary nodules with cavitation and bilateral lower lobe consolidation concerning for septic emboli and pneumonia as well as diminished calibre and poor opacification of the left internal jugular (IJV) concerning for thrombosis, solidifying the diagnosis of Lemierre’s Disease. A Doppler ultrasound of the neck showed diminished flow through the left IJV and a venogram study confirmed the presence of the left IJV thrombus. In consultation with vascular surgery and interventional radiology specialists, it was decided that medical anticoagulation with heparin was preferable over thrombectomy. An abdominal CT on hospital day 9 further revealed bilateral renal infarcts thought to be from septic emboli. The patient completed a course of piperacillin-tazobactam and transitioned from heparin infusion to apixaban once repeat studies showed resolution of LIJV thrombus. She underwent 8 cycles of dialysis over the period of two weeks with subsequent spontaneous return of adequate renal function without need for further dialysis. <strong>Discussion:</strong> Lemierre’s disease presents with fever, sore throat, lymphadenopathy, thrombosis of IJV and metastatic infection to other organs, mainly the lungs. This patient’s case was uniquely complicated by renal infarcts from septic emboli with acute kidney failure requiring hemodialysis. With antibiotics, anticoagulation and hemodialysis, the patient has fully recovered without any long-term organ system deficits.

Evaluating the Diagnostic Paradigm for Group A and Non-Group A Streptococcal Pharyngitis in the College Student Population.

BackgroundAcute pharyngitis is a frequent illness presenting in outpatient settings. Antibiotics are only recommended for bacterial pharyngitis caused by group A β-hemolytic streptococci (GAS); however, infections with non–group A β-hemolytic streptococci (NGAS) have similar clinical presentations and are common in young adult populations. The objective of this study was to analyze the performance of a current (expert) diagnostic algorithm for GAS pharyngitis, the Centor score, and compare it to alternative models developed to predict GAS and NGAS in a college student population.MethodsElectronic health records were obtained for all patients who received a streptococcal rapid antigen detection test (RADT) and/or a bacterial throat culture (n = 3963) at a southeastern US university in 2014. Bivariate and multivariable regression models (least absolute shrinkage and selection operator [LASSO] and stepwise-selected) were fitted to assess and compare their diagnostic performances for GAS-positive and NGAS-positive infections.ResultsPrevalence of GAS was 18.8%. In the subset of RADT-negative patients who received bacterial throat cultures (n = 313), growth of NGAS occurred in 34.8%, with group C streptococci the most frequent isolate. Mean Centor score was higher for NGAS (3.2) vs GAS (2.9) infections (P = .0111). The area under the curve (AUC) for GAS prediction was 0.64 using the Centor score and 0.70 using the LASSO model. For NGAS, the most important features were cough, pharyngeal erythema, tonsillar exudate, and gastrointestinal symptoms (AUC = 0.63).ConclusionsGAS and NGAS pharyngitis were indistinguishable among college students in this study utilizing a commonly applied decision score. Alternative models using additional clinical criteria may be useful for supporting diagnosis of this common illness.

The High Necessity of Rapid Antigen Detection Test (RADT) use to Guide Antibiotic Prescribing Pattern for Acute Pharyngotonsillitis in Syria

The objectives of this study were to assess the percentage of the inappropriate antibiotics prescribing for clinically diagnosed Group A β-hemolytic streptococcus (GABHS) caused acute pharyngotonsillitis (APT), and to investigate factors influencing this prescribing and the possibility and necessity of routine usage of RADT for rational treatment of APT in different primary care facilities in Latakia, Syria. Throat swabs were collected from 80 patients, ≥ 5 years old, seen in urban or rural pharmacies, otolaryngology clinic or emergency unit of University Tishreen hospital over a period of 6 months, who were diagnosed and treated for APT depending on clinical findings. RADT was applied and McIsaac score (MIS) was recorded for all patients. Throat cultures were done only for negative RADT cases seen in the hospital. The chi square (χ2) statistical test was used for comparing categorical variables. A P value of &lt;0.05 was considered significant. Antibiotics were prescribed for 59 patients (74%) among them RADT results were positive for only 9 patients (15.25%) with a percentage of inappropriate antibiotic prescribing of (84.75%). Cultures were GABHS negative for all negative RADT cases. The most frequently prescribed antibiotic was azithromycin (50.8%). Antibiotics prescribing was significantly influenced by the presence of fever (P=0.041), anterior cervical adenitis (P=0.0003), and MIS≤0 (P=0.0001). We found a significance association of the presence of tonsillar exudate (P=0.013) and MIS≥4 (P=0.002) with positive RADT results. There was no significant difference in antibiotic prescribing according to age, sex or place of consultation. Our findings highlight the great need to use RADT in clinical practice as important adjuvant tool in APT diagnosis to reduce the percentage of antibiotic prescribing and so limiting of bacterial resistance.

Successful treatment of thrombotic thrombocytopenia with cerebral sinus venous thrombosis following Ad26.COV2.S vaccination

Successful treatment of thrombotic thrombocytopenia with cerebral sinus venous thrombosis following Ad26.COV2.S vaccination