What are the 8 organisms which cause pharyngitis/diptheria/mumps?
Mumps virus (Paromyxovirus)
Review of the Defense Mechanisms
1. Mucociliary lining of nasal cavity
2. The adenoids and tonsils in the upper respiratory tract in the back of the throat
3. Layer of mucus and ciliated cells covering the lower portion of the upper respiratory tract.
4. Normal flora in upper respiratory tract
5. Respiratory Secretions: lysozyme, sIgA, lactoferrin, mucus
6. Alveolar macrophages in the lower respiratory tract
What 3 organisms cause otitis media?
What 3 organisms causes URDs as opportunistic infections in AIDS patients?
Candida spp. (Thrush)
What structures are included in the the upper respiratory tract? What are connected to the URT?
Nose, mouth, throat, epiglottis, and larynx
Middle ear and paranasal sinuses
What structures are included in the lower respiratory tract?
Trachea, bronchi, bronchioles, and lung alveoli.
What is pharyngitis? Is there coryza associated? What is the main (90%) cause? 50% of all cases occurred from which ages?
Painful inflammation with generalized erythema of pharynx,
Usually NOT associated with coryza, but CAN happen when caused by viruses
90% are caused by Viruses.
50% of all cases occurred from age 5 - 24.
What is Tonsilitis?
Local infection of tonsils = red, swollen with exudate.
What is Diphtheria? What is Mumps?
Corynebacterium diphtheriae infection usually affecting the mucous membranes of your nose and throat.
Viral infection, primarily causes inflammation of the parotid glands (parotitis)— one of three pairs of salivary glands.
What are the symptoms of pharyngitis?
Odynophagia (Painful swallowing)
Enlarged lymph nodes/glands in neck
Occasionally a runny nose and/or postnasal drip (when due to viruses)
In rare cases, difficulty breathing (severe)
A 10 year old child returns from summer camp with Pharyngitis and Pharyngoconjunctival fever. The patient had non exudative pharyngitis, bilaterial conjuctivitis, and rinitis .
What organism do you suspect?
What test would you run first and why?
We would run:
Do gram stain and if gram pos cocci determine if beta hemolytic on blood agar (rule out S. pyogenes)
Pharyngitis; Pharyngoconjunctival fever
- - NON-exudative pharyngitis - -
Clinical Presentation; Do gram stain and if gram pos cocci determine if beta hemolytic on blood agar (rule out S. pyogenes); Ag detection
TX: No specific antiviral therapy
Vaccine new military recruits; not general ppl
Respiratory, fecal-oral, aerosols, fomites, poorly chlorinated pools - water
Anyone, Highest incidence in Spring BUT most freq infants and children
What does adenovirus also cause?
Also causes occular disease, patients can present with tearing as well!
What is the clinical presentation of adenovirus in children? In adults?
Children - can cause upper respiratory infection with rhinitis sometimes with conjuctivitis.
*Can also cause pharyngoconjunctival fever* often associated with camps. (SPRING)
**Bilateral conjuctivitis in which bulbar and palpebral conjuctivae have granular appearance
Rinitis (Inflammation of the nasal mucous membranes), sore throat and cervical adenopathy (enlarged and enflamed lymph nodes of the neck)**
Adults - sore throat; gradual fever; cough; pharyngeal edema and tonsillar enlargement with little or no exudate; NO CONJUNCTIVITIS in adults!
A 3 year old child that attended a day care presented with pharyngitis with ulcerative lesions on the posterior oropharynx. No purulent discharge was observed. The child admitted to sharing drinking glasses with others in the class who had a sore throat.
What pathogens do you suspect?
What pathogen do you need to eliminate?
If the pathogen is acid resistant what organism do you suspect?
1. Viruses associated Pharingitis
2. Group A Streptococcus
3. Coxsackie Virus
ssRNA, Positive sense
has a nucleocapsid (is resistant to acid)
Fecal-Oral/Person-to-Person - respiratory droplet - airborne
Primarily infants and young children
Incidence is higher in summer and fall seasons
Herpangina --> pharyngitis with vesicular/ulcerative eruptions on the posterior oropharynx
Non-exudative; vesicular/ulcerative lesions
Take cultures to rule out bacterial infection (Grp. A strep)
No vaccines; avoid sharing of eating and drinking utensils in families.
*Beta Hemolytic on BAP*
Humans; carriage does occur
HIGHLY contagious - Respiratory droplets, exudates, fomites
Infects ALL ages; but primarily a disease of kids, Highest incidence in winter and spring,
Group A Streptococcus (GAS)
**Pharyngitis, Fever; usually no cough
Picture shows: Tiny red spots in throat and/OR Tonsillar EXUDATE**
Posterior Pharynx: erythematous**
**Gp A Strep. Beta Hemolysis (pathogenic)
**Susceptible to bacitracin and will not
grow around a bacitracin containing disk**
Gram positive cocci staining
Rapid Strep test
**A negative rapid ID could still be positive!! Test is very specific but not as sensitive so you can get false negatives!!!!**
What are the important VFs for Strep. Pyogenes?
*M protein (associated rheumatic fever)*, hyaluronic acid capsule, C5a peptidase, Pilus, fibronectin binding proteins, Streptokinase, DNases, Streptolysins, superantigenic toxins
What is the Tx, Prevention, and Sequelae for Strep. Pyogenes?
Penicillin G, Erythromycin or oral Cephalosporin
Immediate treatment --> prevent rheumatic fever
but DOES NOT prevent acute glomerulonephritis
Prevention: Early everything
1. Scarlet Fever - erythrogenic toxins - requires lysogenized strain
2. Rheumatic Fever - preventable
3. Glomerulonephritis - not preventable
4. Bacteremia and strep. toxic shock syndrome
5. Tonsillitis, sinusitis, otitis media
What is Rheumatic Fever? How is it Dx? Prevented?
First attack is in young ppl:
* inflammatory changes in the heart - (carditis),
* joints (arthritis),
* blood vessels and
* subcutaneous tissues
fever and rash
Preventable if WITHIN 10 days of start of GAS pharyngitis
What are the revised Jones Criteria for Acute Rheumatic Fever (ARF)?
Need two major OR one major and two minor criteria. *
* Major Criteria:
* Chorea --> involuntary jerky movements
* Erythema Marginatum --> target lesions; pale centers with rounded margins
Subcutaneous Nodules --> immune complex deposition which are usually located over extensor surfaces * of the knees, wrists and elbows.
* Minor Criteria:
- Previous rheumatic fever or rheumatic heart disease
- Acute phase reactants: Leukocytosis, elevated sedimentation rate (ESR) and C-reactive protein (CRP)
- Prolonged P-R interval
- Evidence of preceding streptococcal infection -->
- Increased anti-streptolysin O or other streptococcal antibodies
- Throat culture
- Rapid strep carbohydrate antigen test
- Recent scarlet fever.
Strep M type 12
- It's an acute inflammation of the renal glomeruli
- immune complex deposition on the BM --> Type III HSR -
- Symptoms are edema, hypertension, hematuria, proteinuria; fatigue from anemia or kidney failure.
- Uneventful recovery in the young
- In adults, there is progressive, irreversible loss of renal function
- No specific therapy for Glomerulonephritis. Use supportive care.
*BUTYRIC ACID as a byproduct of metabolism which gives off a "fatty" odor* --> lipase +
Human oral cavity and large bowel
Overgrowth of normal flora
*Anaerobic biotyping (culture and sensitivity)*
*Catalase and oxidase negative*
**Beta hemolytic on BAP
*Lipase positive (degrades lipid and produces butyric acid)*;
*Gas Liquid Chromatography for fatty metabolite identification.* .
Grows on * Viande-Levure medium * with 5% blood for 2 days (SLOW GROWTH)
- 'granular' surface
*Treatment use - ampicillin-sulbactam, piperacillin-tazobactam or ticarcillin-clavulanate depending on sensitivity data. Metronidiazole - Tx for anaerobes* AS-PT-TC-Met
Complication of Fusobacterium Necrophorum?
*LEMIERRE syndrome*, pharyngitis that did not resolve after 5 days
- Bacteremia - signs are night sweats, and RIGORS,
- *Suppurative Thrombophlebitis (vein inflammation due to blood clot)
of the internal jugular vein*,
- and metastatic infections .
Human considered the primary reservoir
Respiratory (this is diff from Fusobacterium Necrophorum)
Maximum incidence occurring among those aged 15-25 years.
Neuraminidase --> invasion
Phospholipase D (PLD) --> acts on sphingomyelin to do tissue damage
Pharyngitis followed by an exanthem (rash)
- Pharyngeal erythema with tonsillar exudate and lymphadenopathy
Exudate is patchy and gray-to-white;
Difficult to scrape off
No red spots
Usually develops 1-4 days AFTER the pharyngitis
- Erythematous (redness), pruritic (itchy), urticarial (hives), scarlatiniform (resemble scarlet fever), and maculopapular (rash with spots and bumps)
- Begins on the extensor surfaces of the extremities - most severe
- Spreads to the neck and trunk
- Usually spares the face, palms, soles, abdomen and the buttocks
- Usually lasts > 2 days;
- No long-term sequelae have been noted
*Cultures may be discarded in error*
*Biotyping: ferments glucose, maltose, and lactose*
* Causes liquefaction of gelatin.*
Treatment: ECC - *Erythromycin, clindamycin ,and cephalosporins .*
*Yeast which produces pseudohyphae*
*Disease due to overgrowth*
*If occurs in young and otherwise healthy person this could indicate HIV infection or other serious underlying disease*
*Clinical Disease: Oral Thrush*
*Forms WHITE, adherent, painless patches in the mouth, tongue, or esophagus*
- difficult to remove
What is Thrush Tx?
**For Non HIV patients -
*Nystatin (swish and swallow) - can be non palatable; sucrose and over time can cause cavities*
*Fluconazole if neither above satisfactory*
*For HIV patients*
**Topical Therapy - nystatin or clotrimazole troches
**Azole therapy - fluconazole and itraconazole. Posaconazole effective for oropharyngeal candidiasis
*Fluconazole - effective and convenient. Better tolerated than Topical therapies*
**Itraconazole solution as effective as Fluconazole and more effective than Topical therapy
BOXED*Azoles should not be used if patient pregnant. Amphotericin B is recommended for esophageal candidiasis during pregnancy*BOXED
A 6 year old child presents with fever chills, a sore throat, lymphadenopathy, painful swallowing. He had difficulty breathing because of a thick, gray membrane covering his throat and tonsils.
What organism do you suspect?
What other conditions can be associated with difficulty in breathing?
How should you treat the patient?
Left-sided Heart Failure
Treatment: Early administration of the diphtheria antitoxin Penicillin or erythromycin; and Respiratory support.
Coryneform (club shaped) -->
Chinese character grouping is due to "snapping" division
- 1. Non-lysogenized by bacteria viruses
- 2. Normal flora in nasopharynx, upper respiratory tract, GI, skin;
- 3. Asymptomatic carriers of lysogenized bacteria occur
Respiratory or person to person spread
Virulence Factor: Diphtheria toxin (DT) A-B exotoxin on lysogenized phage
Note: Clinical disease due to the toxin
What does it inhibit and how?
How is the production of the toxin regulated?
What do low levels of iron do?
High levels of iron?
Inhibits protein synthesis via ADP ribosylation/inactivation of EF-2.
Toxin production is under regulation via DTxR
- which is a IRON DEPENDENT repressor protein
Low levels of iron --> DTxR inactive,
does NOT repress toxin gene --> toxin produced
High levels of iron, DTxR active, represses toxin --> no toxin produced
Low Iron levels --> ?
High Iron levels --> ?
LOW IRON LEVELS - TOXIN PRODUCED
HIGH IRON LEVELS - TOXIN NOT PRODUCED
What does the toxin do to the tissue?
sore throat, lymphadenopathy, hoarseness, painful swallowing
*Difficult or rapid breathing occurs due to the development of a THICK, GRAY MEMBRANE COVERING THROAT AND TONSILS**
* = Pseudomembrane (is pathognomonic) containing neutrophils, necrotic epithelial cells, erythrocytes, and bacteria in a fibrin mesh*
Covers tonsils, uvula, and palate
* DIFFICULT TO DETACH without damaging underlying tissue - BLEEDS when attempt is made to remove it *
"Bull Neck" appearance found in severe cases with periglandular edema extending from cheek to clavicle
Perforation of the soft palate: a late effect of pharyngeal diphtheria
Anterior Nasal Diptheria
What kind of membrane is seen? Why is this disease mild?
How is it acquired?
Results in what kind of ulcer?
Anterior Nasal Diphtheria
Mild and chronic with one sided nasal discharge
- ~ common cold - nasal discharge may become blood-tinged
- A WHITE MEMBRANE usually forms on the nasal septum.
- Disease is usually fairly mild because of apparent poor systemic absorption of toxin
Acquired through skin contact
More common than respiratory form
Results in a chronic nonhealing ulcer
Chronic until you get rid of organism producing THE TOXIN
An 18 year old patient presents with a temperature of 40C and frequent episodes of rigors. Clinical examination of the oropharynx showed ulceration and erythema. The patient had a history of pharyngitis that did not resolve after 5 days. The patient had swollen and tender anterior cervical adenopathy, tonsillar exudates, and a lack of cough.
What pathogen do you suspect?
What tests would you order to test your theory?
What complication would you suspect?
What pathogen do you suspect? Fusobacterium necrophorum
What tests would you order to test your theory?
Beta hemolytic on BAP (the degree of beta hemolysis depends on the subtype), Catalase and oxidase negative; indole positive, lipase positive; Gas Liquid Chromatography for fatty metabolite identification.
What complication would you suspect? Lemierre syndrome
In all 3 diseases, the organism does not invade the tissue, the exotoxin is absorbed through mucosa and carried in the circulation to distant organs.
- Cardiac arrhythmias, myocarditis
- Neuritis, peripheral neuropathy and motor paralysis. Paralysis of the soft palate is most frequent during the third week of illness.
- Eye muscles, limbs, and diaphragm paralysis can occur after the fifth week.
- Secondary pneumonia and respiratory failure may result from diaphragmatic paralysis.
- 10-30% mortality rate due to complications
Clinical presentation, culture, toxin assay
Microscopy - UNRELIABLE: false positives, false negatives
Pleomorphic gram-positive rods with club-shaped swelled ends; NO spores
Can appear to be banded beaded with irregularly staining granules
*CYSTIENE-POTASSIUM TELLURITE MEDIUM inhibits growth of most normal flora*
*Corynebacterium diphtheriae produce gray-black colonies in 24-48 hours* (which other diphtheroids do not.)
Immunodiffusion Assay (ELEK test- confirmation, tests for toxin)
PCR of toxin gene
Picture of: Ouchterlony,precipitin
ELEK Test- Abs against DT on paper (vertical line) --> come out and form IC with toxin --> line of precipitate
*Early administration of the diphtheria antitoxin*
*Penicillin or erythromycin*
DPT (toxoid) vaccine series followed by boosters; anyone who's been in contact as well.
Induces cell-cell fusion = multinucleated giant cells - syncytia
F - fusion peplomer
H - hemagglutinin peplomer
Transmission: Worldwide distribution; Respiratory or person-to-person.
Risk Factors/High Risk Populations: Unvaccinated
Diagnosis: Hemeagglutinin Inhibition
HAI: virion + a patient's serum (that may or maynot have Abs). Add RBC's; if patient is infected and has Abs --> they will bind virion and block it from binding to the RBC's --> Hemagluttination Inhibition means the test is POSITIVE for the patient having those Abs
--> If the results show NO Hemagglutination
Inhibition --> patient doesnt have those Abs.
Treatment and Prevention:
Vaccine: live attenuated MMR
A= NO AGGLUTINATION ("RED BUTTON")
TEST + FOR MUMPS
Swelling of parotid glands, fever, self limiting
Swollen, painful salivary glands on one or both sides of your face, causing the cheeks to puff out
Infection/enlargement can be unilateral or bilateral
Can involve the submandibular gland as well.
Pain with chewing or swallowing
Weakness and fatigue
- One third asymptomatic BUT contagious
- So contagious prior to onset of symptoms
- May also find Orchitis: painful swelling of testes - most often unilateral.