Lyle Affleck, 25 -year old, male, Caucasian, college student.
Chief Complaint: A sore throat
History of Present Illness: This is a 25 years-old patient who came to clinic complaining of a sore throat. Seven days ago, he developed a fever, which was low 99F, to moderate grade 101.1F. This was associated with swollen and tender neck glands. He has a sore throat but denies having a cough. He has no abdominal pain but feels as if his upper abdomen has been swollen and he has lost his appetite. He has no nausea or change in bowel movements. Since yesterday patient noticed that his eyes and skin had turned a yellow color. He has no past medical history of jaundice, hepatitis, blood transfusion, body piercing, tattoos or eating shellfish. He has not drink, smoke cigarettes, or use illicit drugs. He does not take any medications. He has not traveled recently. He is sexually active and is in a monogamous relationship with his girlfriend of two years who is experiencing similar symptoms. He is heterosexual and has had two previous sexual partners. He always used condoms. He received Hepatitis B vaccination before starting college. The patient does not have any allergies.
Past Medical History: He has no past medical history.
Surgical History: Patient denied previous surgery.
Family History: Family history is non-contributory.
Social History: Patient is a student. He denied use of tobacco, alcoholic drinks or illicit drug.
Review of the Systems
Skin: no lesion, warm to touch with yellowish discoloration.
HEENT: No headache, dizziness, no blurred vision, PERRLA, EOMI, icteric sclera, pink conjunctivae, T-P erythematous with exudate.
Neck: posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged.
Respiratory: patient denied any difficulty breathing, no cough.
Heart and lungs: Normal
Gastrointestinal: Abdomen: Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quadrants on palpation. He has lost his appetite.
Genitourinary: no complaint on voiding.
Neurologic: the patient is awake, alert, and oriented x4, speech is clear and concise, cranial nerve intact. Normal muscle tone, no loss of sensation; deep tendon reflexes are 2/4. There was no identifiable deficit with motor coordination.
Musculoskeletal: no muscle aches, no pain or tenderness.
Physical examination: areas of physical examinations that are important for this patient are the following: Head and neck especially pharynx, upper palate, lymph nodes, abdomen, especially spleen. PPE: Patient is well-developed, in no acute distress. He appears concerned and anxious. With a temperature of 101.4*F. tympanic. Icteric sclera, pink conjunctivae, T-P erythematous with exudate. Neck: posterior cervical lymph nodes swollen, tender and movable, bilaterally. Supraclavicular lymph nodes not enlarged. Skin is positive for jaundice. Abdomen: Normal bowel sounds, liver – 14 cm in midclavicular line by percussion, diffuse tenderness over both right and left upper quadrants on palpation.
Primary Diagnosis: The primary considerations at this point are strep throat, viral pharyngitis, and infectious mononucleosis.
The Epstein-Barr virus, commonly referred to as EBV, belongs to the Herpes virus family and is one of the common human viruses. It infects people worldwide and many contract infections with EBV at some point during their lives. In childhood, EBV usually causes no symptoms or very mild brief illnesses. Young children have their clinical symptoms more likely milder and may appear as an uncomplicated viral URT infection. In adolescence and young adults, the most common primary infection caused by EBV is infectious mononucleosis, also known as the “kissing disease” due to its oral transmission (McCance, & Huether, 2014, pg. 1011).
The most commonly recognized clinical syndromes present with anterior and posterior cervical lymphadenopathy, severe pharyngitis, fever, with other prominent constitutional symptoms such as fatigue (McCance, & Huether, 2014, pg. 1011). The illness in adults and adolescents lasts much longer that typical courses expected with streptococcal pharyngitis.
Differential Diagnoses:
In most instances, sore throat results from direct infection of the pharynx (pharyngitis), primarily from viruses and partly also from bacteria. Within the American setting, viral pharyngitis is the most common cause of sore throats among adults, and thereof has a wide differential (Rimion et al., 2011).
Infectious mononucleosis is most prevalent among patients aged 15 to 30 years (Kang et al., 2009). Infectious Mononucleosis presents with the classic triad of fever, pharyngitis (sore throat), and posterior cervical lymphadenopathy which patient is experiencing (Naviglio, Abate, Chinello, & Ventura, 2016). It can be ruled in or out by doing a peripheral smear looking for the presence of atypical lymphocytes and doing a heterophile antibody test (McCance, & Huether, 2014, pg. 1012.). Management of IM is usually supportive.
Bacterial pharyngitis. Patients do not present with a cough, rhinorrhea or conjunctivitis. Infections mostly occur in increased temperate climates such as winter and early spring. Gonococcal pharyngitis occurs in persons with an active sexual life who engage in oral-genital sex. It presents with classical symptoms of a severe sore throat, fever, dysuria, with a characteristic green exudate. No distinguishing findings are prevalent on a physical exam. Definitive diagnosis is obtained by culturing a throat sample collected on selective media. Effective treatment with a third-generation cephalosporin (ceftriaxone) is effective in preventing complications, transmission and further dissemination (Shulman et al., 2012).
Group A beta-hemolytic streptococcus (GABHS) infection: symptoms of s strep throat include pharyngeal swelling and erythema, edematous uvula, tonsillar exudates, anterior cervical lymphadenopathy and palatine petechiae. When untreated, the infection lasts between seven to ten days. Untreated streptococcal infection patients are infectious during the acute phase of their infection (explaining the infected partner) with an additional one week (Rimoin, Hoff, Fischer Walker, & Hamza, 2011). The infectious period is drastically shortened to 24 hours by effective antibiotic treatment., and the symptoms also to one day, and thereof prevents most complications (Skoog et al., 2016; Nakhoul & Hickner, 2013).
Complications of GABHS include peritonsillar abscess and rheumatic fever which have a much lower prevalence than perceived. Patients presenting with peritonsillar abscesses may have a “hot potato voice,” asymmetric deviation of the uvula and a fluctuant peri-tonsillar mass (Skoog et al., 2016). The correct clinical impression in most instances is accurate in diagnosing the peri-tonsillar abscess. Conduction of an intraoral ultrasound examination is an accurate diagnostic measure if an abscess is suspected. Rheumatic fever is rare and should be suspected in patients presenting with subcutaneous nodules, erythema marginatum, joint swelling, or heart murmurs with an accompanying confirmed diagnosis of strep A in the preceding month. Lab tests reveal elevated levels of antistreptolysin-O titer and ESR (Shulman et al., 2012).
Post-streptococcal glomerulonephritis is also a known complication of untreated GABS Pharyngitis. Treatment with antibiotics does not prevent it. Classical presentations include hematuria, and more frequently edema in the setting of a confirmed recent case of infection in elevated levels of antistreptolysin-O titer. Another complication is scarlet fever that presents as an erythematous, punctate, sandpaper-like, blanchable exanthema. The rash is present around the groins, the neck and axillae with a punctuation of creases and folds (Pastia’s lines). Patients may have a bright red tongue with white coatings (strawberry tongue). Tonsils and the pharynx are erythematous and covered in exudate (Shulman et al., 2012).
Plan
General Approach
consider a variety of illnesses. Infectious causes range from benign viruses to GABHS. Reflux diseases, allergies and rarely neoplasms may present and inflammation. Important historical elements to be considered include the onset, progression, severity of symptoms and duration of symptoms, presence of comorbidities, and exposure to infections. Examination of the pharynx is important for underlying exudates, masses, foreign bodies, hypertrophy, adenopathy, and petechiae. Evaluating the patient’s hepatosplenomegaly and listening for hear murmurs are necessary especially in patients with Streptococcal pharyngitis (Rimion et al., 2011).
Diagnostics
Strep assay was done, and it turned out to be positive. It is recommended though that throat culture for confirmation is done for those with negative rapid antigen test to reduce the unnecessary use of antibiotics (McIsaac, Kellner, Aufricht, Vanjaka, & Low, 2004).
Screening: No screening indicated
Rx: Amoxicillin 500 mg/125 mg by mouth every 12 hours for ten days and instructed to finish the course of the medication even if he feels better already to prevent complications such as rheumatic fever, or abscess formation. Ten day’s therapy is recommended to maximally eradicate group A streptococcus (Bisno, Gerber, Gwaltney, Kaplan, & Schwartz, 2002). Development of a typical maculopapular rash as a side effect of amoxicillin therapy is to be expected.
Education: Home instructions: increase oral fluid intake and rest; avoid close contact with anyone with strep throat; avoid germs; wash hands often; gargle with a solution of 1/4 teaspoon of salt mixed in 1 cup of warm water; stick to foods that are soft and easy on the throat (applesauce and yogurt are good choices) or warm and soothing (such as broth or tea); stay away from anything spicy or acidic; get lots of sleep and drink a lot of water; change toothbrush;
Consult/Referral: Alert Provider if the following occur during treatment: fever recurs after being normal for a few days, new symptoms appear, such as nausea, vomiting, earache, cough, swollen glands, skin rash, severe headache, nasal drainage, or shortness of breath, joints become red or painful.
Follow-up: To come back to the clinic after two days if still with fever or no improvement of symptoms. Check for a maculopapular rash as a side effect of amoxicillin treatment.
References
Kang, M.-J., Kim, T.-H., Shim, K.-N., Jung, S.-A., Cho, M.-S., Yoo, K., & Chung, K. W. (2009). Infectious mononucleosis hepatitis in young adults: Two case reports. The Korean Journal of Internal Medicine, 24(4), 381–387. doi:10.3904/kjim.2009.24.4.381
McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease in adults and children. St. Louis: Mosby.
McIsaac, W., Kellner, J. D., Aufricht, P., Vanjaka, A., & Low, D. (2004). Empirical validation of guidelines for the management of pharyngitis in children and adults. Journal of American Medical Association, 291(13), 1587-1595. doi: 10.1001/jama.291.13.1587
Nakhoul, G. N., & Hickner, J. (2013). Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics. Journal of general internal medicine, 28(6), 830-834.
Naviglio, S., Abate, M. V., Chinello, M., & Ventura, A. (2016). Splenic Infarction in Acute Infectious Mononucleosis. Journal of Emergency Medicine (0736-4679), 50(1), e11-e13. doi: 10.1016/j.jemermed.2015.09.019
Rimoin, A., Hoff, N., Fischer Walker, C., & Hamza, H. (2011). Treatment of Streptococcal pharyngitis with once-daily Amoxicillin versus intramuscular Benzathine Penicillin in low-resource settings: a randomized controlled trial. Clinical Pediatrics, 50, 535-542. doi: 10.1177/0009922810394838
Shulman, S. T., Bisno, A. L., Clegg, H. W., Gerber, M. A., Kaplan, E. L., Lee, G., Martin, J. M., Van Beneden, C. (2012). Clinical practice guideline for diagnosis and management of group: A streptococcal pharyngitis: 2012 update by infectious disease society of America. Clin Infect Dis (2012), 55(10): e86-e102. Doi:10.1093/cid/cis629
Skoog, G., Edlund, C., Giske, C. G., Mölstad, S., Norman, C., Sundvall, P., & Hedin, K. (2016). A randomized controlled study of 5 and 10 days’ treatment with phenoxymethylpenicillin for pharyngotonsillitis caused by streptococcus group A – a protocol study. BMC Infectious Diseases, 161-6. doi:10.1186/s12879-016-1813-7
Thompson, A. E. (2015). Infectious Mononucleosis. JAMA: Journal of the American Medical Association, 313(11), 1180. doi:10.1001/jama.2015.159
