7. Due to streptococci:
• Spreads by close contact and through air
• Spread more in crowded areas (KG, school, army..)
• Most common among 5-15 age group
• More frequent among lower socio-economic classes
• Most common during winter and spring
• Incubation period 2-4 days
/ 42 7
8. Signs/symptoms
Sore throat
Anterior cervical LAP
Fever > 38 C
Difficulty in swallowing
Headache, fatigue
Muscle pain
Nausea, vomiting
/ 42 8
Tonsillar hyperemia /
exudates
Soft palate petechia
Absence of coughing
Absence of nose drip
Absence of hoarseness
9. Viral tonsillitis/pharyngitis
• Viral tonsilo-pharyngitis is most common.
• Rhinovirus (most common).
• Symptoms usually last for 3-5 days.
Having additional rhinitis, hoarseness, conjunctivitis and
cough
Pharyngitis is accompanied by conjunctivitis in adenovirus
infections
Oral vesicles, ulcers point to viruses
/ 42 9
12. Laboratory
• Throat swab culture
• Gold standard
• Rapid antigen test
• If negative need swab
• Sensitivity of 80% and specificity of
95%.
• ASO
• May remain + for 1 year
• WBC count
• Peripheral smear
/ 42 12
13. Throat Culture
• Pathogens looked for
• Group A beta hemolytic streptococci
• C. diphteriae (rare)
• N. gonorrhoeae (rare)
• Not required usually. Needed only when suspicion is high
and rapid strep throat swab is negative.
/ 42 13
15. Aim of Treatment
• Prevention of complications
• Starting treatment within 9 days is enough to prevent ARF
• Symptomatic improvement
• Bacterial eradication
• Prevention of contamination
• Reducing unnecessary antibiotic use
/ 42 15
16. Treatment of GABHS
A) Symptomatic: Saline gargles,
analgesics, cool-mist humidification and
throat lozenges.
B) Antibiotics:
a) Benzathine Pn-G 1.2 million units
IM x 1 OR Pn V orally for 10 days
b) For Pn allergic pts:
Erythromycin 500mg QID x 10 days
OR Azithro 500 mg Qdaily x 3 days.
/ 42 16
17. Antibiotics NOT to be used for GABHS
• Tetracycline
• Sulphonamides
• Co-trimoxasole
• Cloramphenicole
• Aminoglycosides
/ 42 17
18. GABHS
• Control culture after full dose treatment?
• NO
• If history of ARF:
• Take control culture after treatment
• No need to screen or treat carriers
/ 42 18
19. Mc Isaac Scoring
• Developed by Mc Isaac and friends
• Decreases antibiotic usage by 48%
• No increase in throat swabs
/ 42 19
20. Mc Isaac Scoring
Clinical Findings Score
Fever > 38 C 1
Absence of coughing 1
Tonsillary hypertrophy or
exudates
1 (If < 6 years give 0)
Sensitivity at the anterior
cervical nodes
1
Age 3 – 14 1
Age > 45 -1
/ 42 20
21. Mc Isaac Scoring
Total score Suggestions
0 - 1 points No culture, no antibiotics
2 - 3 points Take culture (or antigen test),
order antibiotics only if
GABHS +
4 - 5 points Take culture (or antigen test),
order antibiotics only if
GABHS +.
If the c/f is severe, start
antibiotics without testing
/ 42 21
22. Antibiotics in Tonsillitis/pharyngitis due to GABHS
ORAL
Penicilline V Children:2x250 mg or 3x250mg,10 days
Adults:3x500 mg or 4x500mg,10 days
PARENTERAL
Benzathine penicilline Adults:<27kg:600 000 U single dose, IM
>27 kg:1.200 000 U single dose, IM
ALLERGY TO PENICILLINE
Erithromycine estolate 20-40 mg/kg/day, 2x1 or 3x1, 10 days
Erithromycine ethyl succinate 40 mg/kg/day, 2x1 or 3x1, 10 days
/ 42 22
23. Acute Otitis Media
• The diagnosis of AOM requires
the presence of a middle ear
effusion and acute signs of middle
ear inflammation
• AOM not responding to
treatment: Sustained clinical and
otoscopy findings despite 48-72
therapy
• Recurrent atitis media: 3 AOM
attacks within 6 moths or 4
attacks within 1 year
/ 42 23
25. AOM causes
• S. pneumoniae 30%
• H. İnfluenzae 20%
• M. Catarrhalis 15%
• S. pyogenes 3%
• S. aureus 2%
• No growth 10-30%
• Chronic otitis media: P. aeruginosa, S. aureus, anaerobic bacteria
/ 42 25
26. Acute Otitis Media
• 85% of children up to 3 years experience at least one,
• 50% of children up to 3 years experience at least two attacks
• AOM is usually self-limited. Rarely benefits from antibiotics.
• 81 % undergo spontaneus resolution.
/ 42 26
27. Signs and Symptoms
•Symptoms
•Autalgia
•Ear draining
•Hearing loss
•Fever
•Fatigue
•Irritability
•Tinnitus, vertigo
•Otoscopic findings
•Tympanic membrane
erythema
•Inflammation
•Bulging
•Effusion
•Hearing loss
/ 42 27
28. Antibiotics
First choice
Amoxicilline 40 mg/kg/day, 3 doses
Trimet./Sulfamethoxazole 8mg TM/40mg SMX/kg 2 dose
Second choice
Amoxicilline/clavulanate 45 mg/kg/day, 2 doses
Erythromycin 40-50 mg/kg/day, 3 doses
Reurrent AOM prophylaxis
Sulfisoxazole 75 mg/kg/day, single dose 3-6 mo
Amoxicilline 20 mg/kg/day, sinle dose 3-6 mo
/ 42 28
30. Sinusitis
Acute sinusitis
• Str. pneumoniae %41
• H. influenzae %35
• M. catarrhalis %8
• Others %16
Strep. pyogenes
S. aureus
Rhinovirus
Parainfluenzae
Veilonella, peptokoccus
Chronic sinusitis
• Anaerob bakteria:
Bactroides, Fusobacterium
• S. aureus
• Strep. pyogenes
• Str. pneumoniae
• Gram (-) bakteria
• Fungi
/ 42 30
31. Acute Sinusitis
• Paranasal sinuses:
• Frontal
• Ethmoid
• Maxillary
• Sphenoid
• Most common during childhood
• Maxillary
• Ethmoid
• After age 10
• Frontal
/ 42 31
32. Acute Bacterial Sinusitis
• Causative agents are usually the normal inhabitants of the
respiratory tract.
• Common agents:
Streptococcus pneumoniae
Nontypeable Haemophilus Influenzae
Moraxella Catarrhalis
/ 42 32
33. Signs and Symptoms
• Feeling of fullness and pressure over the involved sinuses, nasal
congestion and purulent nasal discharge.
• Other associated symptoms: Sore throat, malaise, low grade fever,
headache, toothache, cough > 1 week duration.
• Symptoms may last for more than 10-14 days.
/ 42 33
36. Diagnosis
• Based on clinical signs and symptoms
• Physical Exam: Palpate over the sinuses, look for structural
abnormalities like DNS.
• X-ray sinuses: not usually needed but may show cloudiness and air
fluid levels
• Limited coronal CT are more sensitive to inflammatory changes and
bone destruction
/ 42 36
38. Treatment
• About 2/3rd of patients will improve without treatment in 2
weeks.
• Antibiotics: Reserved for patients who have symptoms for
more than 10 days or who experience worsening
symptoms.
• OTC decongestant nasal sprays should be discouraged for
use more than 5 days
• Supportive therapy: Humidification, analgesics,
antihistaminics
/ 42 38
39. Antibiotics
a) Amoxicillin (500mg TID) OR
b) TMP/SMX ( one DS for 10 days).
c) Alternative antibiotics: High dose amoxi/clavunate,
Flouroquinolones, macrolides
/ 42 39
40. Acute Rhinosinusitis
• Most important: Headache and postnasal dripping
• Common in fall, winter and spring.
• Face congestion
• Fever, fatigue, headache increased by leaning forward
• Nose obstruction
• Nose dripping
• Purulent secretions (rhinoscopy)
• Sensitivity over the sinuses
• Halitosis
/ 42 40
41. Acute rhinosinusitis
Rhinitis
• Increased symptoms after 5 days
• Symptoms resolve in 10-14 days
• Decreasing viral symptoms, nasal secretion becoming more purulent
are indicative for acute rhinosinusitis
41
42. Diagnosis
• Direct x-ray
• Diffuse opacification
• Mucosal thickening >4 mm
• air-fluid level
• Sinus aspiration
• Rarely performed
• Nasal endoskopy
• Tomography
• More sensitive compared with direct x-ray
• Indicated before surgery
/ 42 42
44. Treatment
• Antibiotics questionable
• Stalman: 192 patients. No difference between placebo and
doxycycline.
• Van Buchem: 214 patients. No difference between amoxycilline and
placebo.
• Lindbaek: 130 patients. compared Pen V, Amoxycilline and placebo.
86 % of patients receiving antibiotics and 57% of patients receiving
placebo improved.
/ 42 44
45. Antibiotics for Sinusitis
• Amoxycilline (Alfoxil) 3x500mg/d PO 10 d
• Amoxycilline/clavulonate (Augmentin) 3x625 mg/d PO 10 d
• Cefuroxim (Zinnat) 2x250 mg/d PO 10 d
• Azithromycine (Zitromax) First day 1x500 mg, then 1x250 mg/d PO 5 d
/ 42 45
47. Laryngitis
• Most commonly upper respiratory viruses
• Diphtheria
• C. diphtheriae produces a cytotoxic exotoxin causing tissue necrosis at site
of infection with associated acute inflammation. Membrane may narrow
airway and/or slough off (asphyxiation)
/ 42 47
48. Acute epiglottitis
• H. influenza type B
• Another cause of acute severe airway
compromise in childhood
/ 42 48
50. Acute Bronchitis
• The cough in acute bronchitis most often lasts from 10 to 20
days
• Chronic bronchitis: cough and sputum production on most days
of the month for at least three months of the year during two
consecutive years
• Etiology: A)Viral
B) Bacterial (Bordetella pertussis, Mycoplasma
pneumoniae, and Chlamydia pneumoniae)
• Diagnosis: Clinical
• S/S: Productive cough, rarely fever or tachypnea.
/ 42 50
55. Influenza
• Sudden onset after 12-24 hours incubation
• General weakness and fatigue
• Feeling cold, shivering, temp. Up to 39-40 C
• No sore throat or running nose
• Severe back, muscle and joint pain
/ 42 55
57. DISEASE
• Influenza A virus cause
• worldwide epidemics (pandemic)
• major outbreaks of influenza
• occurs virtually every year.
• Influenza B virus cause
• major outbreaks of influenza
/ 42 57
58. VIRUS
• Segmented (8 segments in types A & B, 7 in type C) ssRNA
genome
• Helical nucleocapsid
• Outer lipoprotein envelope
• The envelope is covered with two different types of spikes, hemagglutinin and
a neuraminidase.
• Hemagglutinin binds cell surface receptor, to initiate infection.
• Neuraminidase releases progeny virus from infected cells.
• The internal ribonucleoprotein is the group specific antigen
that distinguishes influenza A, B and C.
/ 42 58
59. ORTHOMYXOVIRUSES
M1 protein
helical nucleocapsid (RNA plus
NP protein)
HA - hemagglutinin
polymerase complex
lipid bilayer membrane
NA - neuraminidase
Type A, B, C : NP, M1 protein
Sub-types: HA or NA protein
60. ANTIGENIC CHANGES
• Influenza viruses especially type A show changes in
antigenicity of hemagglutinin (H) and neuraminidase (N)
proteins.
• Antigenic shifts:
• major changes based on the reassortment of RNA segments. It occurs only
with influenza A.
• Other theories of antigenic shift includes:
• Recirculation of existing subtypes
• Gradual adaptation of animal viruses to human transmission
• Antigenic drifts:
• minor changes based on mutations in the RNA genome.
61. • Animal viruses (aquatic birds, chicken, swine) are the source of RNA
segments that encode antigenic shift variants.
• Because influenza B virus is only a human virus, there is no animal
source of new RNA segments. Influenza B virus shows only antigenic
drift, but not shift.
63. A / PHILIPPINES / 82 (H3N2)
A group antigen of influenza A
Philippines / 82 location and year the virus isolated
H3N2 Hemagglutinin and Neuraminidase types
H1N1 and H3N2 strains of influenza A are the most common types
at this time and are the strains included in the current vaccine.
64. Past Antigenic Shifts
1918 H1N1 “Spanish Influenza” 20-40 million
deaths
1957 H2N2 “Asian Flu” 1-2 million deaths
1968 H3N2 “Hong Kong Flu”700,000 deaths
1977 H1N1 Re-emergence No pandemic
At least 15 HA subtypes and 9 NA subtypes occur in
nature. Up until 1997, only viruses of H1, H2, and H3 are
known to infect and cause disease in humans.
66. CLINICAL FINDINGS
• Incubation period 24 – 48 hours
• Fever, myalgias, headache, dry cough, photophobia, shivering
• Resolve spontaneously in 4 – 7 days. Influenza B is similar to A, but
influenza C is usually subclinical or milder in nature.
67. COMPLICATIONS
• Tracheobronchitis and bronchiolitis
• Primary viral pneumonia
• Secondary bacterial pneumonia
• usually occurs late in the course of disease, after a period of
improvement has been observed for the acute disease. S.
aureus is most commonly involved although S. pneumoniae
and H. influenzae may be found.
• Myositis and myoglobinuria
• Reye's syndrome
• Reye's syndrome is characterized by encephalopathy and
fatty liver degeneration. It occurs in children with viral
infection and are taken aspirin to reduce fever. The disease
had been associated with several viruses; such as influenza A
and B, Coxsackie B5, echovirus, HSV, VZV, CMV and
adenovirus.
68. LABORATORY DIAGNOSIS
• Virus Isolation
• Throat swabs, NPA and nasal washings may be used for virus
isolation. It is reported that nasal washings are the best
specimens for virus isolation. Influenza viruses isolated from
embryonated eggs or tissue culture can be identified by
serological or molecular methods.
• Rapid Diagnosis by Immunoflurescence
• cells from pathological specimens may be examined for the
presence of influenza A and B antigens by indirect
immunofluorescence.
• Serology
• Demonstration of a rise in serum antibody to the infecting
virus
69. TREATMENT
• Amantidine
• The only effective against influenza A.
• Act at the level of virus uncoating.
• Both therapeutic and prophylactic effects.
• Significantly reduces the duration of fever (51 hours as opposed to
74 hours) and illness.
• 70% protection against influenza A when given prophylactically.
• Rimantadine is an amantadine derivative but not as effective as
amantadine and less toxic.
70. PREVENTION
• Vaccine
• killed influenza A (HINI and H3N2 isolates) and B viruses
• Protection lasts only 6 months
• Yearly boosters are recommended
• Should be given to people
• Older than 65 years
• With chronic respiratory diseases
• With chronic cardiovascular diseases.
• Immunity to Influenza
• Antibody against hemagglutinin (H) is the most important
component in the protection against influenza viruses.
71. AVIAN INFLUENZA
Avian influenza A viruses usually do not infect humans
Rare cases of human infection with avian influenza viruses have been
reported since 1997 with avian influenza A (H5N1) viruses
All strains of the infecting virus were totally avian in origin and there was
no evidence of reassortment.
Infection in humans are thought to have resulted from direct contact with
infected poultry or contaminated surfaces.
To date, human infections with avian influenza A viruses have not resulted
in sustained human-to-human transmission.
