Dr Shobhika ,DrC Jayakumar ,DrPraveena Bhaskaran ,DrNavya George
AIMS KOCHI
11 month old immunised for the age male child presented with high Grade intermittent fever of 7 days ,cough,loose stools,diffuse erythematous rash over body.The child was on treatment for the same from another hospital
The child was febrile,sick looking.But vitals stable
Clinical examination of throat showed extensive white patch covering uvula,tonsils and pharynx with surrounding erythema.
Child appeared very toxic and child could not take any thing orally till threat patch was cleared at least partially after four days of antibiotics
systemic examination was normal.
No evidence of Immuno deficiency like chronic diarrhoea ,Recurrrnt otitis ,recilurrent boil recurrent pneumonia and deep seated abscess or osteomyelitis
Diffentials:
EBV
Candida
Step pharyngitis
Agranulocytosis
Diphtheria
Labs : CRP-91.14mg/l
TLC-27.75 ,PMN 90%L10%
EBV IgM and culture blood were negative
Peripheral smear – microcytic hypochromic anemia with neutrophilic leucocytosis.
Immunoglobulin profile done was normal for age.
Occult blood and stool reducing substances were positive.
Throat culture- staphylococcus aureus (MRSA)(moderate growth)
CT neck- ill defined inflammatory edema and fluid tracking in left parapharyngeal space at the level of tonsils and adenoids blocking 50% airway.
Diagnostic nasal endoscopy showed thick secretions.
Diagnosis Acute pharyngotonsillitis
Treatment:The child was started with cefepime, metrogyl and vancomycin. After the culture results antibiotics was changed to clindamycin and child improved
Drainage and aspiration not done as the collection very mild and only edema was present in the Parapharyngeal area
Discussion:
Infection of the pharynx and on tonsils are common beyond infancy
Symptoms:Sore throat,fever with sudden onset,enlarged tonsils
We have excluded Diphtheria Clinically as the child has taken three doses of Pentavac and bacteriological also swab for culture
Even though GABHS is very common cause in older children Staph pharyngitis is reported
Complications:local suppurative complications: parapharyngeal abscess,peritonsillar and retropharyngeal abscess and sepsis.
Non suppurative complications:Acute rheumatic fever,Acute post streptococcal glomerulonephritis.Post streptococcal coccal reactive arthritis and PANDA (Paediatric Acute Neuro Psychiatric Disorder Associated with Streptococci ) syndrome
TSS (Toxic shock syndrome )
etc
Mclsaac score or modified Robert M centor score :
Symptoms:
Body temperature >38 degree C score +1
No cough score +1
Anterior Cervical lymph node score +1,
Exudates Tonsillar swelling score +1
Age:3 -14 yrs score +1
15-44yrs Score 0
>45yrs Score – 1m score 3 and above need treatment with Amox/pencillin or narrow spectrum cephalosporin
Prevention
Strict hand washing and personal hygiene could prevent infection being spread to other people
Take home message :Antibiotics is the main stay for pharyngotonsillitis and culture helps to isolate the organism and to restrict use of antibiotics as most cases of pharyngitis is viral
Rapid antigen detection test may be used for the early identification of GABHS
