Professor Fahad Abdullah Al Zamil
Professor and Consultant, Pediatric Infectious Diseases
Head of Pediatric Infectious Diseases Unit
King Khalid University Hospital
King Saud University
November 7, 2012
Clinical scenario:
18 month year old child with H/O fever for 2 days with poor
sleeping time. His mother notices that he is pulling his right
ear.
• What is the diagnosis?
•What do you expect to see in the physical examination?
Normal Tympanic Membrane
Otitis media (in Latin) is the inflammation of the middle ear, or middle ear
infection.
It occurs in the area between the tympanic membrane and the inner ear,
including a duct known as the eustachian tube. It is one of the two most
common causes of earache - the other being otitis externa. Diseases other
than ear infections can also cause ear pain, including cancers of any
structure that shares nerve supply with the ear and shingles which can lead
to herpes zoster oticus. Though painful, otitis media is not threatening and
usually heals on its own within 2–6 weeks.
Diagnosis
Acute otitis media is usually diagnosed via visualization of the tympanic membrane in
combination with the appropriate clinical history. The use of a monocular otoscope and
perhaps a tympanometer may not be able to distinguish bacterial versus viral etiology,
especially if the canal is small and there is wax in the ear that obscures a clear view of the
eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to
distension of the small blood vessels on it, mimicking the redness associated with otitis
media.
The occurrence, duration, or severity of symptoms is not predictive of an ear infection in
the absence of examination of the eardrum.
Clinical scenario
An 18-month-old girl is seen by her GP. A mild fever of 38.0
degrees Celsius, hoarseness, a barking cough, and
symptoms over the last 48 hours, which are worse at night,
have been noted.
1.) What is the diagnosis?
2.) What three organisms are most likely to be responsible
3.) What are your immediate actions in the Emergency
Department?
4.) What three drugs may be useful in treatment?
Streptococcus Pharyngitis
Granular
Pharyngitis
Pharyngitis
Pharyngitis comes from the Greek word pharynx
meaning throat and the suffix -itis meaning
inflammation. It is an inflammation of the throat.
In most cases it is quite painful, and is the most
common cause of a sore throat.
Like many types of inflammation, pharyngitis can
be acute – characterized by a rapid onset and
typically a relatively short course – or chronic.
Pharyngitis can result in very large tonsils which
cause trouble swallowing and breathing.
Pharyngitis can be accompanied by a cough or
fever, for example, if caused by a systemic
infection.
Most acute cases are caused by viral infections
(40–80%), with the remainder caused by bacterial
infections, fungal infections, or irritants such as
pollutants or chemical substances. Treatment of
viral causes are mainly symptomatic while
bacterial or fungal causes may be amenable to
antibiotics and anti-fungal respectively.
Cause
The majority of cases are due to an infectious organism acquired from close contact with an
infected individual.
Infectious
Viral These comprise about 40–80% of all infectious cases and can be a feature of many
different types of viral infections.[2][3]
•Adenovirus – the most common of the viral causes. Typically the degree of neck lymph node
enlargement is modest and the throat often does not appear red, although it is very painful.
•Orthomyxoviridae which cause influenza – present with rapid onset high temperature,
headache and generalised ache. A sore throat may be associated.
•Infectious mononucleosis ("glandular fever") caused by the Epstein-Barr virus. This may
cause significant lymph gland swelling and an exudative tonsillitis with marked redness and
swelling of the throat. The heterophile test can be used if this is suspected.
•Herpes simplex virus can cause multiple mouth ulcers.
•Measles
•Common cold: rhinovirus, coronavirus, respiratory syncytial virus, parainfluenza virus can
cause infection of the throat, ear, and lungs causing standard cold-like symptoms and often
extreme pain.
Bacterial
A number of different bacteria can infect the human throat. The most common is Group A
streptococcus, however others include Corynebacterium diphtheriae, Neisseria gonorrhoeae,
Chlamydophila pneumoniae, and Mycoplasma pneumoniae.
Streptococcal pharyngitis
A case of strep throat
Streptococcal pharyngitis or strep throat is caused by group A
beta-hemolytic streptococcus (GAS).
It is the most common bacterial cause of cases of pharyngitis
(15–30%). Common symptoms include fever, sore throat, and large
lymph nodes. It is a contagious infection, spread by close contact
with an infected individual. A definitive diagnosis is made based
on the results of a throat culture. Antibiotics are useful to both prevent
complications and speed recovery.[8]
Diagnostic approach
Modified Centor score Points Probability of Strep Management 1 or less <10% No
antibiotic or culture needed 2 11–17% Antibiotic based on culture or RADT 3 28–35% 4 or
5 52% Empiric antibiotics It is hard to differentiate a viral and a bacterial cause of a
sore throat based on symptoms alone. Thus often a throat swab is done to rule out a
bacterial cause.
The modified Centor criteria may be used to determine the management of people
with pharyngitis. Based on 5 clinical criteria, it indicates the probability of a
streptococcal infection.
One point is given for each of the criteria:
•Absence of a cough
•Swollen and tender cervical lymph nodes
•Temperature >38.0 °C (100.4 °F)
•Tonsillar exudate or swelling
•Age less than 15 (a point is subtracted if age >44)
•The McIsaac criteria adds to the Centor:
•Age less than 15: add one point
•Age greater than 45: subtract one point
The Infectious Disease Society of America however recommends against empirical
treatment and considers antibiotics only appropriate following positive testing.
Testing is not needed in children under three as both group A strep and rheumatic
fever are rare, except if they have a sibling with the disease
Management
The majority of time treatment is symptomatic. Specific treatments are
effective for bacterial, fungal, and herpes simplex infections.
Medications
•Analgesics such as NSAIDs and acetaminophen can help reduce the pain
associated with a sore throat. (Note: Don't use salicylates, like aspirin, for
influenza: Increased risk of Reyes Syndrome)
•Steroids (such as dexamethasone) have been found to be useful for severe
pharyngitis.
•Viscous lidocaine relieves pain by numbing the mucus membranes.
•Antibiotics are useful if a bacterial infection is the cause of the sore throat.
For viral infections, antibiotics have no effect.[22]
•Oral analgesic solutions, the active ingredient usually being Phenol, but
also less commonly Benzocaine, Cetylpyridinium chloride and/or Menthol.
Chloraseptic and Cēpacol are two examples of brands of these kinds of
analgesics.
Alternative
Alternative medicines are promoted and used for the treatment of
sore throats. However, they are poorly supported by evidence;
UpToDate, an evidence-based peer-reviewed resource, recommends
that they not be used to treat pharyngitis.
Epidemiology
Acute pharyngitis is the most common cause of a sore throat and sore
throat and cough is diagnosed in more than 1.9 million people a year
in the United States.
Diarrheal disease
•Diarrheal disease is the second leading cause of death in
children under five years old. It is both preventable and
treatable.
•Diarrheal disease kills 1.5 million children every year.
•Globally, there are about two billion cases of diarrhoeal
disease every year.
•Diarrheal disease mainly affects children under two years
old.
•Diarrhea is a leading cause of malnutrition in children under 5
years old.
Diarrheal diseases affect people of all ages throughout the world. Children, however, are the most
vulnerable; diarrhea is the second leading causes of death worldwide in children under the age of
five, accounting for approximately 1.5 million deaths per year.1 More than 80% of these deaths occur
in Africa and Southeast Asia.2