Transcript Strep throat

Case Presentation
By Jesper Aurup
Triage
• 47yo Female with dyspnea
• T-100.6, PR- 110, BP- 142/86, RR- 20, O2- 99% on NC 15L, BMI-84
• “Inhaled roach spray”
Chief Complaint
“I inhaled some Roach powder and it hurts to breathe”
History of Present Illness
• 47yoF with PMH of asthma, HTN, sleep apnea, arthritis, and
hyperlipidemia presents with dyspnea of acute onset. The patient has felt
weak for the past few days and has had a sore throat and trouble
swallowing for the past 2 days. She stated that her throat had been
feeling dry and it hurt to breathe. She stated drinking water helped to
alleviate the pain. At 3:30pm on the day of her presentation to the ED,
the patient was cleaning and putting away a roach powder that then fell
out of the cabinet exploded up into her face and she stated that she
inhaled some of it. At 5:00pm the patient began having a cough, nausea,
and feeling feverish so she took 2 Tylenols PO. The patient then took 2
puffs of her albuterol inhaler to help with her cough. Later, she still felt ill
and her daughter convinced her to call an ambulance.
• Pertinent Positives: Fever, cough, sore throat, pain on swallow, nausea,
dyspnea
• Pertinent Negatives: No chest pain, stiff neck, stridor, drooling, inability
to swallow, headache, abdominal pain, vomiting, or recent sick contacts
Other History, Allergies, and Medications
• PMH: Asthma, HTN, Hyperlipidemia, Sleep apnea, Arthritis
• PSH: Gastric Sleeve March 2015, C Section 1993
• FH: Mother had CAD, Father had Diabetes Type 2, Daughter has
asthma
• SH: lives with her daughter. Former smoker. 20 pack year history
• All: Motrin – rash, Advil – rash
• Meds: albuterol nebulizers
Physical Exam
• Vital Signs: T-100.6, PR- 110, BP- 142/86, RR- 20, O2- 99% on 2L,
BMI-72
• Gen: Minimal distress, sitting upright, able to hold conversation
• CV: s1s2, regular rhythm, tachycardic, no mgr
• Resp: CTAB, good air entry, no wheezes, no stridor, no accessory
muscle use, no drooling
• HEENT: PERRLA, EOMI, no palpaple cervical adenopathy (limited
exam due to obese neck), however was tender to palpation over
anterior neck, erythematous oropharynx, white tonsillar exudates
bilaterally
Roach Powder- Generally Boric Acid is
Poisonous Ingredient
• Symptoms:
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Blue-green vomit
Diarrhea
Bright red rash
Fever
Low BP
Decreased UO
Drowsiness
• Management:
• ABCs
• IV fluids
• Gastric Lavage and
Activated charcoal if
ingested
Differential Diagnosis of Sore Throat
• S.P.I.T.
• Severe – Epiglottitis, Peritonsillar Abscess, Ludwig Angina
• Probable – Viral Pharyngitis, Bacterial Pharyngitis
• Interesting – Retropharyngeal abscess
• Treatment – Evaluate the need for supportive care with
or without antibiotics
Clinical Presentation
Diagnosis
Treatment
Epiglottitis
Sudden Onset of Fever
Drooling
Tachypnea
Toxic Appearing
Lateral Cervical
Radiography
Urgent ENT consult
Cefuroxime Antibiotic
Therapy
Retropharyngeal Abscess
Fever
Sore throat
Stiff Neck
No Trismus
Lateral Radiograph or CT
Surgical drainage
Penicillin and
Metronidazole
Ludwig Angina
Submaxillary mass with
elevation of tongue
Jaw swelling
Fever
Trismus
Lateral cervical radiograph
or CT
Stabilize airway
Surgical drainage
Penicillin and
Metronidazole
Imaging and EKG findings
• Chest X ray – No pleural effusion, no focal consolidation, no
pneumothorax, normal heart size, normal heart border
• EKG – Sinus Tachycardia
Laboratory Values
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CBC 10.4>12.0/38.2<250
BMP: Na- 143, K-3.7, Cl- 105, HCO3- 23, BUN- 13, Cr-1.4, Glu-105
LFT: Tbili-04, AlkPhos- 94, AST-11, ALT-10
BHcG- negative
PT- 10.0, INR- 0.9, aPTT-26.7
CPK – 138, TropT- <0.01
Lactate – 0.9
Amylase – 48, Lipase – 12
• AND???????
Rapid Group A Strep Test
Because…. CENTOR Criteria for predicting
Streptococcal Pharyngitis (2)
• Presence of Tonsillar Exudates: 1 point
• Tender Anterior Cervical Adenopathy: 1 point
• Fever by history: 1 point
• Absence of Cough: 1 point
• Age less than 15years old: 1 point
• Age more than 45years old: Subtract 1 point
Our Patient’s Score…. 2 to 3
• Presence of Tonsillar Exudates: 1 point
• Tender Anterior Cervical Adenopathy: 1 point
• Fever by history: 1 point
• Absence of Cough: 1 point
• Age less than 15years old: 1 point
• Age more than 45years old: Subtract 1 point
Assessment and Plan
• 47yoF with positive RAST test and signs and symptoms consistent
with Streptococcal Pharyngitis.
• The patient was given:
• Tylenol 650mg PO
• Dexamethasone PO 10mg
• Penicillin G IM 1.2MIL U
• And discharged home
• Journal of Family Practice July 2013
• A meta analysis of 8 RCTs with an overall population of 806 (children and
adults) was 44% positive for GAS and treated with antibiotics and
allowed traditional analgesia with acetaminophen or NSAIDs with
possible adjunctive corticosteroid vs placebo
• Overall, patients who received corticosteroids were 3 times more likely to
report pain relief at 6 hours and resolution of symptoms at 24 hours. NNT
<4
• In addition, one RCT found that 16% of placebo patients returned for
additional care vs none in steroid group
• Adverse Events: Reported in one RCT (n=125): 3 steroid vs 2 placebo were
hospitalized for rehydration and 3 steroid vs 2 placebo developed
peritonsillar abscess
• Of note, it was found single vs multiple doses were effective with
statistically insignificant differences in results
Clinical Pearls
• The Rapid Strep Test has a Sensitivity of 64.6% and Specificity of
96.79%, with PPV of 80.95% (1)
• Throat Cultures are the Gold Standard for GAS Pharyngitis, but they
require 24-48hours for results(3)
• Treatment of Group A Strep Pharyngitis is to prevent sequelae of GAS
Pharyngitis such as Rheumatic fever and Meningitis (3)
• The most common cause of pharyngitis is viral (3)
• Steroids can be used in Strep Throat for improvement of pain and
swelling. Standard dose is Dexamethasone 0.6mg/kg up to 10mg PO
or IM (3)
References
• 1) Gurol Y, Akan H. The sensitivity and specificity of rapid antigen test
in streptococcal upper respiratory infections. Int J Pediatrics. 2010.
• 2) McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical
Validation of Guidelines for the Management of Pharyngitis in
Children and Adults. JAMA. 2004;291(13):1587-1595.
doi:10.1001/jama.291.13.1587.
• 3) Case Files: Emergency Medicine 3rd Edition