Pharyngitis.

This article reviews the commonly encountered agents causing acute inflammation of the pharynx and tonsils, with special attention to a practical approach for identifying and dealing with the group A beta-hemolytic streptococcus. Ubiquitous viral agents such as Epstein-Barr virus, rhinovirus, and adenovirus are reviewed. Some agents such as group A beta-hemolytic streptococcus and Epstein-Barr virus are susceptible to treatment. Additionally, unusual infectious agents and noninfectious causes of pharyngitis are enumerated.

Tick-borne infections. What starts as a tiny bite may have a serious outcome.

Tick-borne illnesses are being reported increasingly often. Unlike Lyme disease, which tends to be indolent, Rocky Mountain spotted fever and ehrlichiosis can kill and so must be recognized and treated promptly. These diseases require clinical diagnosis, because laboratory confirmation with antibody tests takes too long. Tetracycline hydrochloride, doxycycline (Doryx, Vibramycin), or chloramphenicol (Chloromycetin) treatment is effective. Other diseases (eg, babesiosis, tularemia) are encountered occasionally and can also be fatal but are treatable with antibiotics.

Infectious arthritis.

Infectious arthritis should be suspected in any patient with a swollen joint but especially in children, debilitated patients, immunocompromised persons, those with infection elsewhere (even if on antibiotics), and those with other types of arthritis or a prosthetic joint. Diagnosis depends on obtaining joint fluid for culture and Gram stain. Initial appropriate broad spectrum antibiotics are best narrowed to suit the individual organism, which 2 to 6 weeks of therapy can eradicate. Repeated needle aspiration or surgical drainage is usually helpful in lessening joint damage and achieving a more rapid resolution of symptoms.

Prolonged delirium tremens requiring massive doses of medication.

Delirium tremens might last for weeks and treatment requires massive benzodiazepine doses, yet it is possible to manage patients with this condition successfully. In this case of delirium tremens, standard agents at the usual recommended doses were not sufficient to achieve control of confusion and agitation or to stabilize neurologic and cardiovascular parameters. The patient required extraordinarily high doses of central nervous system depressants for an extended period. Midazolam, a short-acting benzodiazepine, was used but was associated with metabolic acidosis and was extremely expensive. Although high-dose midazolam should probably be avoided, extremely high dose benzodiazepine use for an extended period might be necessary in some cases. In this circumstance we advise diazepam because of its low cost and relative safety. The tendencies to withhold large doses for fear of side effects or to give up in cases requiring prolonged intensive support must be resisted to minimize the mortality from this severe illness.

An approach to pediatric upper respiratory infections.

Upper respiratory tract infections are the most common diseases encountered in office pediatrics. The majority of these illnesses, including the common cold and pharyngitis, are viral in etiology, present with rhinitis and fever, and are self-limited and benign. Management consists of fluids, rest, saltwater nose drops and analgesics. Antihistamines appear to relieve only those symptoms potentiated by allergy. With the exception of streptococcal pharyngitis, upper respiratory tract infections do not require antibiotic therapy. However, otitis media and sinusitis, which sometimes are difficult to diagnose, are markedly improved by antibiotics that cover Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. In 10 percent of children, otitis media and sinusitis are recalcitrant to antibiotic therapy. For these patients, referral to an otolaryngologist, myringotomy, placement of tympanostomy tubes or a short trial of prednisone may be efficacious.

Immunizations.

The primary care physician has few tools as effective as immunization. Patients deserve to be advised about prophylaxis and appropriately treated when the need arises. Monitoring of the CDC's Morbidity and Mortality Weekly Report (MMWR) is the most efficient manner of keeping current. The Journal of the American Medical Association usually quotes the important advances from the MMWR. The local health department is generally helpful in covering local crises or giving travel advice.

Standardized symptomatic treatment versus penicillin as initial therapy for streptococcal pharyngitis.

A multicenter, double-blind, randomized, placebo-controlled trial was conducted to determine whether the addition of penicillin was superior to patient education and anti-inflammatory drug therapy for relief of the acute discomforts of pharyngitis caused by group A beta-hemolytic streptococcus (GABHS). One hundred seventy-eight patients, aged 4 to 29 years, received appropriate symptomatic therapy, including specific doses of aspirin or acetaminophen, plus penicillin (91 patients) or placebo (87) for the initial 48 hours of illness. All had 24-hour office and 48-hour telephone reevaluations. In 123 patients (57 with clinically severe pharyngitis), throat cultures yielded GABHS. Penicillin provided a margin of 20% improvement over anti-inflammatory therapy for the complaint of sore throat only after 48 hours of treatment (for the 123 patients with GABHS, p = 0.01; for the 57 with both severe pharyngitis and GABHS, p = 0.05). No significant improvement was noted for fever, malaise, odynophagia, exudate, adenitis, or pharyngitis. The failure of penicillin to provide much additional benefit makes its routine early prescription specifically for symptomatic relief questionable.

Cellulitis and related skin infections.

The location, appearance and clinical course of a skin infection can be used to make a reasonable assumption about its etiology. By carefully considering such factors as entry site and immunocompetence, the physician can make a rational decision about hospitalization and treatment. When appropriate, traditional antibiotics should be used initially, thereby avoiding the temptation to "overkill" the infection with newer, more expensive agents.

Periorbital and facial cellulitis.

Periorbital cellulitis is a potentially lethal infection which must be rapidly distinguished from a host of self-limited illnesses. It is often associated with sepsis and requires intravenous antibiotics with broad initial coverage because of the wide variety of infecting organisms. A search must be made for an underlying source of the infection. Facial cellulitis is less frequently followed by major complications. It usually responds to oral antibiotics but also requires a careful search for the source of infection.

Rocky Mountain spotted fever: gastrointestinal and laboratory manifestations.

Sixty-six cases of serologically documented Rocky Mountain spotted fever (RMSF) from North Carolina are reviewed. Gastrointestinal manifestations were present in 80% of these patients. Because other common expressions of RMSF occasionally do not accompany severe gastrointestinal dysfunction, improper diagnosis and therapy can result. Sixty percent of the patients had hyponatremia and thrombocytopenia. Over 70% of those who had liver or muscle enzyme evaluations had at least one abnormality. RMSF should be strongly considered in the differential diagnosis of patients with a combination of these findings.