key: cord-0986017-7ums36c9 authors: Shah, Ravi; Bansal, Arun; Singhi, Sunit C. title: Approach to a Child with Sore Throat date: 2011-06-10 journal: Indian J Pediatr DOI: 10.1007/s12098-011-0467-0 sha: 6b91eda92a7f2e7cfd6ac0fc19b261f2cddd704f doc_id: 986017 cord_uid: 7ums36c9 Sore throat is one of the common reasons for outpatient and emergency visits among children. It could be because of several etiologies; of these bacterial pharyngitis is the most important. Major challenge for the clinician is to diagnose group A beta hemolytic streptococcus (GABHS) pharyngitis and diphtheria, which are associated with serious complications. Throat swab smear with culture and rapid antigen tests are useful for making the diagnosis but the later may not be available in resource poor settings. Many clinical scores have been devised to diagnose GABHS with variable success but usually clinical features, epidemiological criteria and expert clinical judgment with or without supportive investigations indicate need for antibiotics. A child with sore throat and toxic look may have diphtheria or parapharyngeal/retropharyngeal abscess, and therefore should be hospitalized. Upper Respiratory tract infections are seen with great frequency in both children and adults and have remarkable economic impact, related to the frequent prescription by physicians of antibiotics, even when the causative agents of infection are not bacteria. About one-fourth of children with sore throat have bacterial pharyngitis and about half of the families with index case have a secondary case [1] . Identification and adequate antibiotic treatment of group A streptococcal sore throat is important for primary prevention of acute rheumatic fever, as it carries approximately 3% risk of development of acute rheumatic fever. Soreness is generally described by the patient as pain in the throat without the effort of swallowing and also a painful swallow [2] . Sore throat is primary symptom of pharyngitis. The terms "sore throat" and "pharyngitis or pharyngotonsillitis" are often used interchangeably. Pharyngitis refers to objective evidence of inflammation of the pharynx, such as exudates, ulceration, or definite erythema. Redness of the throat may occur as part of the general redness of all mucous membranes in a patient with fever. A diagnosis of pharyngitis is justified only when the pharynx is redder than the rest of the oral mucosa. Most sore throats are caused by viruses. Less often, sore throats are due to bacterial infections. Several scoring systems have been developed to predict which patients will have GABHS. Use of these does improve quality of care but none of these systems, however, is totally reliable in identifying children who need treatment [4] . A clinical scoring system has been designed in India but it has to be validated for local use. This scoring system uses variables such as age, season, fever, erythema of pharynx, size of tonsil, pharyngeal exudates; lymphadenopathy and pain in throat, and scores are assigned according to throat culture positivity in association with the same. Cut off value of 15 predicts GAS infection with 91% sensitivity and 98% specificity [3] . The evaluation of patient should include the following: Poor quality of the heart sounds raises the possibility of diphtheritic myocarditis. Absence of a heart murmur or dependent edema should be noted for their relevance to rheumatic fever and glomerulonephritis. Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature ≥38.3°C, tonsillar or pharyngeal exudates and cervical lymphadenopathy. Cough, coryza and diarrhea are more common with viral pharyngitis. Differentiating features between streptococcal pharyngitis and viral pharyngitis are given in Table 2 . A major concern in emergency room for a child with sore throat is not to miss diagnosis of diphtheria and GABHS pharyngitis. & Obtain throat swab for bacterial smear and culture including Albert stains for diphtheria. A provisional diagnosis of diphtheria is suggested if typical drum stick organisms are seen in the smear. However, a definitive diagnosis requires growth of C. diphtherium in culture as diphtheroids are commensals in throat. & Rapid Antigen Diagnostic Tests (RADTs) for GABHS [5, 6] : It is based on nitrous acid extraction of group A carbohydrate antigen from organisms obtained by throat a High sensitivity for GABHS [1] b High specificity for GABHS [1] swab. It is highly specific (>95%), and provides immediate results, but has variable sensitivity. Throat culture confirmation of a negative RADT is recommended to increase sensitivity. Confirmation of positive test is not recommended because of very high specificity. & Other investigations to be done according to clinical possibility. ○ Complete blood count ○ Peripheral blood smears-for atypical lymphocytes. ○ EB virus serology (IgM antibody against VCA(viral capsular antigen)) ○ Streptococcal antibody titre is not useful for diagnosis of streptococcal pharyngitis and is not routinely recommended. Note: antibiotics are indicated in any child who is looking sick and/or suspected to have complications. Throat Swab Sampling Technique Samples should be obtained by vigorous swabbing of both tonsillar surfaces or fossae and the posterior pharynx [6, 7] . Correctly sampled and plated, throat swab culture has 90-95% sensitivity. Swabbing the soft palate and uvula should be avoided, because it dilutes the inoculums. GABHS pharyngitis is self-limiting illness. Antibiotic treatment provides acute symptom relief, prevent suppurative (otitis media, sinusitis, quinsy) and non suppurative complications, and reduce communicability. Antibiotics reduce incidence of rheumatic fever by more than two third [8] . Clinical decision guideline for sore throat is given in Fig. 1 . Clinical features, epidemiological criteria and expert clinician judgment with or without supportive investigation usually indicate need for antibiotics. Currently used score for decision making in pharyngitis has been adapted by adding age to four components of original Centor score (absence of cough, swollen and tender anterior cervical nodes, temperature >38°C and tonsillar exudates or swelling) [9] . Each component is given 1 point; age of 3-14 years carries 1 point while that of 14-44 years, zero. Patients with a score of zero or 1 do not require testing or antibiotic therapy. Patients with score of 2 or 3 should be tested and prescribed antibiotics if found positive while patients with score of 4 or higher, are at high risk of streptococcal pharyngitis and should be given empiric treatment [10] . Based on cost, narrow spectrum of activity, safety, and effectiveness, penicillin is the drug of choice [10, 11] . Shorter duration of treatment increases risk of bacteriological recurrence [12] Inappropriate use of macrolides for treatment of GABHS pharyngitis has been the main cause of resistant strains in western countries [13] . The various alternatives to penicillin and the dosage of antibiotics are given in Table 3 . & Stabilize child (ABC…) (For details refer to section on upper airway obstruction). & Diphtheria antitoxin: 50,000-120,000 U IV depending on extent of involvement. & Antibiotics: Aqueous crystalline penicillin G 40,000 U/ kg/dose 6 hourly IV or erythromycin 15 mg/kg 8 hourly (not to exceed 2 g/day) oral/IV for 14 days. For prophylaxis to contacts same dose of erythromycin for 7 days or a single injection of benzathine penicillin G (600,000 U IM for <30 kg, 1,200,000 U IM for ≥30 kg.) is recommended. & Toxic looking child & Not accepting orally well & Suspected to having associated complications or diphtheria. The rational clinical examination. Does this patient have strep throat? 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