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What Causes Pharyngitis?

Donna M. D'Alessandro, M.D. — Mon, 08 Mar 2010 00:10:32 +0000

Patient Presentation
A 7-year-old male came to clinic with a 4 day history of a sore throat. His mother reports that he also had some voice changes like laryngitis and some mild croupy sounding cough. That morning he came to the kitchen for breakfast crying almost inconsolably because he was in so much pain. He had been going to school and there was strep throat circulating in the community. He also had been taking ibuprofen with some relief. The past medical history was non-contributory and his immunizations were current. The review of systems revealed no fever, chills, rhinorrhea, ear pain, headache, muscle ache, abdominal pain or rash.

The pertinent physical exam showed a slightly tired appearing male who was afebrile and had normal growth parameters. He had a laryngitic sounding voice. HEENT examination revealed erythematous tonsils without exudates. There was no palatal petechiae, but pinpoint vesicles on the soft palate were seen. There was no deviation of the tonsillar pillars. His ears and nose were normal. He had shoddy anterior cervical adenopathy. The rest of his examination was negative. The laboratory evaluation included a rapid streptococcal antigen test that was negative. The throat culture eventually was negative. The diagnosis of viral pharyngitis/laryngitis was made and appropriate instructions were given to the family.

Discussion
Sore throat caused by group A, beta-hemolytic streptococcus (GAS) is classically characterized as a patient with a constellation of various symptoms including fever, headache, emesis, sore throat, palatal petechiae, abdominal pain, sand-papery skin rash and often with a history of close contact. The rapidity of onset is relatively short but generally not characterized as rapid. Patients with upper respiratory tract symptoms or allergic symptoms including rhinitis, conjunctivitis, voice changes (e.g. raspy, croupy, laryngitic) tend to have viral etiologies for their sore throat. Differentiating between viral pharyngitis and GAS is a common conundrum. Rapid antigen testing and throat cultures assist in making the proper diagnosis, so that nonsupprative complications such as acute rheumatic fever or acute glomerulonephritis can be avoided. Serotypes 1,6, and 12 of GAS are associated with these sequelae. Rapid onset of fever, difficulty swallowing, drooling, voice change (particularly muffled or hot-potato), respiratory distress and toxicity may indicate retropharyngeal abscess, peritonsillar abscess, tonsillar hypertrophy caused by Epstein-Barr virus, or epiglottitis. An immunization history should help determine if a patient is at risk for Diphtheria or Haemophilus influenza type b. A careful sexual history of oral-genital contact should be obtained in tweens, teens and young adults looking for the possibility of a sexually transmitted infection.

Learning Point
The differential diagnosis of sore throat includes:

Infectious

Viral
- Adenovirus
- Coxsackie virus
- Echovirus
- Epstein-Barr virus
- Herpes simplex

Bacterial
- Streptococcus, group A, beta-hemolytic
- Streptococcus, groups B, C and G, beta-hemolytic
- Streptococcal pneumoniae
- Staphylococcus aureus
- Arcanobacterium haemolyticum
- Chlamydia trachomatis
- Corynebacterium diphheriae
- Haemophilus influenza type b
- Mycoplasma pneumoniae
- Neisseria gonorrhea
- Tularemia

Fungal
- Candida albicans

Miscellaneous

Epiglottitis
Kawasaki disease
Peritonsillar abscess
Retropharyngeal abscess
Post-nasal drip (allergic, upper respiratory infection)
Tobacco
Trauma
Referred pain (lymphadenitis, otitis media)

Questions for Further Discussion
1. List clinical presentations of group A, beta-hemolytic streptococcus.
2. List the phylogeny of streptoccus species.
3. What are indications for surgical consultation for pharyngitis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sore Throat and Viral Infections and at Pediatric Common Questions, Quick Answers for this topic: Strep Throat

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:306-08.

Inkelis, SH. Sore Throat. in Pediatrics a Primary Care Approach. Berkowitz CD, ed. W.B. Saunders company, Philadelphia, PA. 1996;186-191.

American Academy of Pediatrics. Group A Streptococcal Infections, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;616-628.

ACGME Competencies Highlighted by Case

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Practice Based Learning and Improvement
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

Learning From the Past. What is Chlorosis?

Donna M. D'Alessandro, M.D. — Mon, 01 Mar 2010 00:01:20 +0000

Patient Presentation
A pediatrician was reading for pleasure and came across this passage describing Mary Queen of Scots, just before her ascension as Queen of France when she was 17 years old in 1559: “{England’s ambassdor to France} Throckmorton also noticed that Mary was unwell and she soon had to retire from court in a state of nervous collapse. He found Mary and Henri’s daughter, Marguerite, ’somewhat sickly’ and on 24 May, visitors said she was ‘very ill, pale and green and withal short-breathed and it is whispered amont them [in the French court] that she cannot live long’. By 18 June, one of Mary’s attendants felt that she ‘was very evil at ease and to keep her from fainting were fain to bring her wine from the altar…I never saw her look {so} ill…she cannot long continue’. ”

The diagnosis of Queen Mary’s illness was chlorosis, which the pediatrician had never heard of. She decided to use a literature and Internet search to try to learn more about this adolescent malady.

Discussion
In practicing medicine, clinicians try to provide the best care for the patients and families they serve. They usually try to use the most current information available and apply it to the specific patient situation, yet medicine is an ever-changing science and art. Disease theories change. For example, mental illness was once thought to be caused by the lunar cycles thus the name “lunacy” or “lunatic.” Overtime it became known that neurochemical and genetic factors play a role. Scientific information is re-analyzed or classified. For example, the organism that causes cat-scratch disease has had 3 names since 1991 - Afipis felis, Rochlimacae henselae, and currently Bartonella henselae. Disease treatments are often changing as new information becomes available. For example, up until the early 1990s, intravenous theophylline was widely used for asthma treatment as it was thought to be better than aerosolized albuterol, and oral steroids were not used at all. Likewise “new” diseases are described. Some continue to be a distinct entity because the causative agent is accepted as distinct, such as HIV. Other diseases also continue to be viewed as distinct entities but a causative agent has not been defined or may be multifactorial, i.e. Kawasaki disease. It is only the test of time that allows clinicians to know with more or less certainty if their present information is correct.

Learning Point
Chlorosis was considered a blood dyscrasia that was ill-understood, but feared by people. Clinical descriptions were of teenage and young women with menstrual irregularities who were generally well-nourished but would have a pale coloring of their skin. The skin color was described as greenish and hence the name, but this actually occurred very rarely. The young ladies were always described as having extreme fatigue, to the point that many were felt to be dying. Other descriptions include being a brunette, blond or redhead (depending on the source), and having a bluish cast to the eyes. Possible causes included overwork or underwork, poor hygiene, tight corsets or clothing, spurned love, or sudden shocks or frights. Other names for the disease were norbus virgineus (virgin disease) or greensickness. Many different treatments were promulgated, but the most common one was to marry and begin sexual intercourse. If a woman continued to have episodes after marriage, then increased frequency of intercourse was recommended.

Contemporary accounts of chlorosis go back to ancient history. William Shakespeare described greensickness in 4 plays including 1 where he describes a “male greensickness.” Even in the early 20th century, Henry James’s novel The Wings of the Dove describes a woman who is mortally ill with an ill-defined disease which is often taken for tuberculosis, but which describes chlorosis. Many young girls and women were felt to be dying when they would have these episodes including Mary Queen of Scots, presented above. With newer science, the true cause of chlorosis was determined to be iron deficency anemia and thus over time, chlorosis has had its demise including its own obituary written in 1936.

It is intriguing to think about how history might have changed if the then “modern” understanding of chlorosis was true. In real history, Mary Queen of Scots was truly felt to be dying while she was married to King Francois II. He later died before producing an heir with her. Queen Mary remarried and later had one child, James VI of Scotland who eventually became James I of England and Ireland, effectively unifying the current Great Britain. How would the histories of France, Scotland, England and Europe itself have changed if the prevailing understanding of chlorosis was actually true and Mary had died? How will our understanding of disease today, change the future of the world?

Questions for Further Discussion
1. What changes in medicine have you experienced over your professional lifetime?
2. What other extinct diseases can you name?
3. What is the effect of disease on war?
4. List other histories that were or may have been changed because of disease?

Related Cases

Anemia

Hypotension and Shock

Mental Status Changes

Nutrition / Dietetics

Obstetrics / Gynecology

Teenager

Young Adult

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Anemia and at Pediatric Common Questions, Quick Answers for this topic: Iron Defiency Anemia

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Shakespeare W. Romeo and Julie Act 3 Scene 5.

Shakespeare W. Antony and Cleopatra Act 3 Scene II.

Shakespeare W. King Henry IV Part 2 Act 4. Scene III.

Shakespeare W. Pericles, Prince of Tyre Act 4, Scene VI.

Fowler WM. Chlorosis - An Obituary. Annals of Medical History. 1936:8,168-177.

Time Magazine. Medicine: Chlorosis. April 6, 1936.

Mercer CG, Wangensteen SD. Chlorosis, A Heroine’s Illness in The Wings of the Dove. Journal of the History of Medicine and Allied Sciences. 1985;259-285.

Graham, R. The Life of Mary Queen of Scots, An Accidental Tragedy. Pegasus Books, NY. 2009 page 83.

ACGME Competencies Highlighted by Case

Practice Based Learning and Improvement
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

Systems Based Practice
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Causes Diurnal Enuresis?

Donna M. D'Alessandro, M.D. — Mon, 22 Feb 2010 00:34:14 +0000

Patient Presentation
A 4-year-old male came to clinic with a 1 week history of daytime enuresis. He was toilet trained for urine during the day for 9 months and used diapers at night. Over the past week his babysitter and family noticed that he would be playing, then ran for the bathroom but often would have urinary incontinence. He denied dysuria. Parents denied constipation, but did say that he was urinating more frequently and seemed to be drinking more for the past 3 weeks. The past medical history showed a healthy male. The family history was positive for type 2 diabetes mellitus and hypothyroidism. The social history revealed that his mother had recently returned from a military deployment. The review of systems showed no weight loss, nausea, emesis, or fever. The family denied concerns of abuse.

The pertinent physical exam showed a well appearing male with normal vital signs. His growth parameters were 50-75%. His weight was 16.4 kilograms which was the same as 6 months previously. His mucous membranes appeared slightly dry. The work-up showed a urine dipstick with large ketones and glucose. His glucometer reading was 434 mg/dl and a true glucose was later 612 mg/dl and his hemoglobin A1c was 8.1 %. Thyroid studies were eventually normal. The diagnosis of new onset type 1 diabetes mellitus was made. The patient’s clinical course had him admitted to the hospital where he was started on an insulin drip, and he was later changed to insulin injections and scheduled meals and snacks. His parents and grandparents were educated regarding daily management including common problems such as toddler/preschoolers refusing to eat, management during intercurrent illnesses and emergency treatment for hypoglycemia.

Discussion
Type 1 diabetes mellitus or insulin-dependent diabetes mellitus (DM) is a chronic metabolic disorder caused by the lack of insulin. Langerhans cells in the pancreas make insulin and congenital absence or destruction of the cells produces DM where patients are dependent on exogenous insulin. An estimated 3/1000 children develop DM by age 20. Overall there is an incidence of 15/100,000 annually for DM.

Insulin and diet treatment is necessary but needs to be tailored to the individual. Intercurrent illnesses also require special treatment so patients do not progress to ketoacidosis. To read more about intercurrent illness treatment click here. Patients can also have long-term side effects of their diabetes including other endocrinopathies/autoimmune diseases, growth problems and retinopathy. Endocrinopathies are generally screened for yearly and growth is monitored closely during regular diabetes and well-child care follow-up. Yearly retinopathy screening generally starts ~5 years after diagnosis.

Learning Point
Primary nocturnal enuresis is a common developmental problem in children that improves overtime. Although organic causes can present with primary nocturnal enuresis, these more commonly present with diurnal or daytime enuresis. Secondary diurnal enuresis should raise the clinicians suspicion for further history, careful physical examination, evaluation and management.

Primary enuresis is defined as a child who has never gained urinary control, and secondary enuresis is a child who has gained control and how does not have control. Click on the links to learn more about bladder dysfunction and primary nocturnal enuresis.

The causes of diurnal enuresis include:

Increased urine output
- Excessive water intake
- Diabetes mellitus
- Diabetes insipidus
- Sickle cell anemia
Structural problems
- Epispadias
- Ectopic ureter
- Vesicle sphincter dyssynergy
- Labial adhesions
- Vaginal reflux
- Meatal stenosis
- Posterior urethral valves
Bladder instability or decreased size
- Bladder spasm
- Constipation
- Hypercalciuria
- Pregnancy
- Urinary tract infection
- Vulvitis/vaginitis
Neurological problems
- Spinal cord abnormalities
- Sphincter weakness
Other
- Sexual abuse
- Central nervous system or developmental anomalies
- Foreign body
- Food sensitivities
- Irritation - i.e. soaps, bubble bath, tight undergarments
- Inattention to normal voiding signals - i.e. not paying attention to need to void until too late to void in toilet
- Pinworms
- Stress incontinence (often associated with large bladder capacity)

Questions for Further Discussion
1. What treatments are available for primary nocturnal enuresis?
2. What multiple endocrinopathy syndromes is diabetes associated with?
3. What are the indications for a urology consultation for diurnal enuresis?
4. What workup should be considered for diurnal enuresis?

Related Cases

Toilet Training and Bedwetting

Juvenile Diabetes

Enuresis and Urinary Incontinence

Failure to Thrive and Lack of Normal Physiologic Growth

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Type 1 Diabetes and Bedwetting.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Cooper CS, Nepple KG, Hellerstein S, Glassock EL. Voiding Dysfunction. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1016198-overview (rev. 6/24/08, cited 1/5/10).

Lui P. Urinary Incontinance. Merck Manual.
Available from the Internet at http://www.merck.com/mmpe/sec17/ch228/ch228b.html#sec17-ch228-ch228b-344 (rev. 3/08, cited 1/5/10).

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

Practice Based Learning and Improvement
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

Systems Based Practice
25. Quality patient care and assisting patients in dealing with system complexities is advocated.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What is the Seroconversion Rate of Mumps Vaccine?

Donna M. D'Alessandro, M.D. — Mon, 15 Feb 2010 00:13:37 +0000

A 16-month-old male came to the emergency room with a 2-3 day history of fever to 101° F. He had emesis 3 times over the first two days. His mother noted that he was somewhat fussier when eating but he had good oral intake and urine output. She also thought his left face was slightly swollen. There is documented mumps in his community and he was vaccinated with the measles-mumps-rubella vaccine (MMR) 1 month earlier. The past medical history, family history, and review of systems were negative. The pertinent physical exam revealed him to be afebrile with normal vital signs and growth. HEENT examination showed his pharynx to be minimally erythematous, and diffuse swelling along the lower left mandible. There was a 1 x 1 cm lymph node at the angle of the left mandible and diffuse cervical lymphadenopathy bilaterally. The rest of his physical examination was normal. The diagnosis of of presumed mumps was made. The work-up included serology for mumps IgM, urine culture, and parotid massage with oral culture. A rapid strep test was also negative. The family was sent home with instructions for mumps exposure, oral hygiene precautions, and symptomatic treatment. The patient’s clinical course over the next few days saw him without fever and a decrease in the facial swelling. One week later, the laboratory evaluation was positive for a urine IgM, but was negative for serum or oral culture.

Discussion
Mumps is caused by a paramyxoviridae family virus and humans are the only known host. The spread is from infected respiratory tract secretions. Mumps causes swelling of one or more salivary glands, in particular the parotid glands. Up to 1/3 of patients do not have salivary swelling that is apparent. Parotitis in children is usually not due to mumps and can be caused by several other viruses including coxsackieviruses, cytomegalovirus, enteroviruruses, human immunodeficiency virus, and parainfluenza virus. It can also be causes by Staphlococcus aureus, mycobacterium (nontuberculous), cirrhosis, diabetes, drug reactions and malnutrition.

Mumps complications include central nervous system problems (including hearing problems, cerebellar ataxia, radiculitis), arthritis, myocarditis, mastitis, thyroiditis, myocarditis, oophoritis, orchitis (with rare sterility), and pancreatitis. Death is rare and infection in the first trimester of pregnancy is associated with an increased risk of spontaneous abortion. It does not appear to increase the risk of congenital malformations. Most cases are in children 5-15 years of age. Incubation is 16-18 days but can occur between 12-25 days after exposure. Highest infectivity is from 1-2 days before the parotid swelling to 5 days after the swelling, but the virus may be shed from 7 days before swelling to 9 days after.

In 2006, a resurgence occurred in the United States, with the highest attack rate among persons aged 18-24 years and 57% of patients had previously received 2 doses of vaccine. In 2007 and 2008, incidence declined but unfortunately another outbreak occurred in 2009, mainly among unimmunized or underimmunized populations.

Learning Point
Mumps vaccine is highly effective. Its effectiveness has been estimated at 73%-91% for 1 dose and 76%-95% for 2 doses. However these recent outbreaks may show that vaccine induced immunity may wane after > 10 years since the second dose of vaccine.

Recommendations for vaccination are that MMR be given at 12-15 months of age and again at 4-5 years of age. Recommendations for potentially susceptible individuals during an outbreak should be individualized based upon age and can be found from the Centers for Disease Control.

Questions for Further Discussion
1. What is the seroconversion rate for measles vaccination?
2. What is the seroconversion rate for hepatitis A vaccination?

3. What are the potential side effects of MMR vaccination?

Related Cases

Mumps

Childhood Immunization

Immunization

Fever and Fever of Unknown Origin

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Mumps and Immunization.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

American Academy of Pediatrics. Mumps, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;468-472.

Centers for Disease Control. Mumps Outbreak — New York, New Jersey, Quebec, 2009. MMWR. November 12, 2009 / 58(Dispatch);1-4
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d1112a1.htm?s_cid=mm58d1112a1_e (rev. 11/12/2009, cited 12/17/2009).

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competency performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.

Practice Based Learning and Improvement
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital