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Tonsillopharyngitis - Complications, diagnosis, and treatment

Created by Ian Mannarino.

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Video transcript

- [Voiceover] Tonsillitis and pharyngitis are two infections that commonly go together. Tonsillitis is, of course, swelling of the tonsils which if we take a look at this mouth sometimes you can see peeking out of the corner between two arches. Specifically, they're the palatine tonsils. They're located somewhat close to the palate, the roof of the mouth. The pharynx is the back of the throat. So pharyngitis is inflammation in the back of the throat. Tonsillitis and pharyngitis together can be often called tonsillopharyngitis. Diagnosis of tonsillopharyngitis has to do with figuring out whether it's a virus, or a bacteria. The infection is viral about 90 percent of the time in adults. However, in children, viral illnesses account for about 70 percent. The vast majority of the remaining percentage is from bacterial illnesses. Specifically, there's one bacteria that we have to watch out for. In fact, you may know it as strep throat. The bacteria that causes strep throat is known as streptococcus pyogenes. Another name for this bacteria, is Group A Strep which I'll just abbreviate, G-A-S, Group A Streptococcus. For viral illnesses, treatment essentially is just resting, waiting it out, and treatment of symptoms. However, for a bacteria, these infections can actually be treated with antibiotics. It's not just symptomatic treatment. Because we can actually treat the infection, it's important to try to tell the difference between the two. This is important from a public health standpoint because an untreated streptococcal infection, is contagious for up to two to three weeks. However, as soon as antibiotics are started for a strep infection, patients will remain contagious for only about 24 to 48 hours. So as I was saying from a public health standpoint, treatment is important because we can stop this infection from being passed from one person to the other. However, the other major reason to treat strep throat is that there can be complications that arise if this infection is not treated. For example, some patients may develop a rash that can start on their body. They'll also develop a very high fever, and sometimes they can develop a swollen tongue. This enlarged swollen tongue, high fever, and body rash is known as scarlet fever. This usually happens along with the infection at the same time as the sore throat. Other complications can develop two to three weeks after a strep throat. One complication can be a very serious one, and it's probably one of the most feared complications of an untreated strep throat, and that's called rheumatic fever. Now rheumatic fever, you may have heard rheumatic before if you've ever heard of rheumatoid arthritis, or maybe a rheumatologist. That word relates to the joints. In rheumatic fever, patients may experience severe joint pain so these poor kids will be screaming in pain from all this joint pain. But probably a more scary complication, and one that can cause lasting damage is the heart problems. Patients may develop murmurs and heart issues. Rheumatic fever is a very serious complication. Of course, rheumatic fever, patients have a fever as well. Another complication that can develop is known as glomerulonephritis. That's kind of a big word, but let me break it down for you. The word neph refers to the kidney. Nephron, nephritis, that's all the kidney. Itis is inflammation, so this is inflammation in the kidney, but specifically it's inflammation in the glomerulus of the kidney. The glomerulus is the filtration system of the kidney so the issue here is that the filtration system of the kidney is inflamed. This can cause some issues. For example, patients may be urinating blood. Because of the inflammation, some of the glomeruli, the filtration unit, become damaged, and this releases blood into the urine. Also, because the glomerulus is inflamed, patients may not be able to filter out fluid so they hold onto fluid in their body. This leads to a higher blood pressure. Just like rheumatic fever, this can occur two to three weeks after a Group A Strep infection. The reason for these time differences is scarlet fever occurs at the same time from bacteria that releases toxins. So scarlet fever is toxin mediated. Rheumatic fever and glomerulonephritis are caused by the immune system. The immune system has ramped up to fight off the infection, and some of the products that are created specifically antibodies that are created by the immune system accidentally react with our own body. After some time, the body will clear these antibodies, and the patient will recover from either rheumatic fever or glomerulonephritis. Those are the complications that can arise, but how do we actually diagnose strep throat? Again, like I said, diagnosis has to do with trying to figure out whether it's a viral or a bacterial illness. How can we determine whether it's caused by Group A Strep? There's a few really good strong clinical indicators. Patients may develop a fever with bacterial strep throat. Viral illnesses do not as commonly lead to a fever. Another big sign is that patients will have no cough. In fact, patients just have a really red, and scratchy throat, very, very sore, very painful sore throat. This can cause difficulty swallowing. Patients may also develop what are known as exudates. These exudates are a combination of fluid, white blood cells, and cellular debris, and bacterial debris as well. It's kind of similar to pus. So you've go all this pus developing, these exudates on the tonsils, and in the back of the throat. Most commonly this is seen on the tonsils, but it can be seen in the back of the throat. Last of all, in the patient's neck, patients may get swollen glands, also known as swollen lymph nodes, or in other words, lymphadenopathy, will develop in the neck. A combination of a fever, no cough, very sore throat, maybe these exudates, and tender and enlarged neck lymph nodes may suggest strep throat. But to confirm a suspected strep throat, a clinician should do two things. First of all, they should get what's known as a rapid strep test. This tests for a bacterial component on the surface of the bacteria that's specific to Group A Strep. Group A Strep has a carbohydrate, or in other words, a sugar on its cell's surface that's specific to it. The rapid strep test tests for this sugar. This test is actually very easy to perform. A physician or a health practitioner will take a long Q-tip, and swab the back of the throat. This can be painful, or annoying for patients, but it's fairly quick so patients don't experience this pain or discomfort for a long period of time. It's just really quick. The great thing about this test is it only takes about 10 to 20 minutes to run. If it's positive, then the patient should be treated. However, if the rapid strep test is negative, it doesn't necessarily mean that the patient doesn't have strep throat. Actually, the problem with this test is it's not very sensitive. So this test may actually miss the diagnosis. Because the accuracy is not always the best for the rapid strep test, getting a throat culture is also recommended. This is done in a similar way. A physician or a health practitioner will swab the back of the throat. This material, this mucus, that gets on the cotton swab is used to grow out a culture. This is usually done on a Petri dish. The problem with this is the growth of the bacteria may actually take some time. Whereas, the rapid strep test was indeed very rapid. It only took 10 to 20 minutes. A throat culture may actually take about two to three days to grow out. But a throat culture is very accurate, and confirms diagnosis of strep throat. There's also another test that can be done that's not for bacteria, but actually for viral pharyngitis. That's called the monospot test, specifically a test for the viruses that cause mononucleosis, also known as mono. This is the kissing disease. Teenagers end up getting this most commonly. The monospot test tests for one of two viruses that cause mono, specifically Epstein-Barr virus, EBV. If this test is positive, then it indicates that the patient is affected by EBV. However, patients can still have mono but have a negative test. That's if they're affected by a different virus, CMV, cytomegalovirus. For treatment, remember as I said, if it's a virus, treatment is only going to include supportive measures, perhaps gargling with salt water, using pain relievers, and, of course, rest. For viruses, there will only be supportive measures. For bacteria, patients should still get this symptomatic treatment, but also they should receive antibiotics. Currently, penicillin is the antibiotic of choice to be given for bacterial pharyngitis. However, if a patient is allergic to penicillin, the next best class of antibiotics is known as the macrolides. These include erythromycin, azithromycin, clarithromycin, so on, and so forth. Keep in mind that these antibiotics could change in the future. If Group A Strep becomes resistant to these antibiotics, we'll have to pull out bigger guns, and stronger antibiotics to help fight them. That's actually why it's very important to remind patients to take a full course of antibiotics. If patients don't take a full course of antibiotics, then the bacteria may survive. Because it was exposed to this antibiotic, but still lived, it may actually develop resistance. It's very important to remind patients to finish their full course of antibiotics. This full course is about seven to ten days. In order to avoid the complications, and to prevent the patient from being contagious and spreading to other people, it's important to diagnose bacterial pharyngitis, and treat patients accordingly.