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Internal MedicineInfectious DiseaseSore Throat And Or Rhinorrhea

Sore Throat And Or Rhinorrhea

Introduction

Sore throat (pharyngitis) and rhinorrhea are among the most frequent reasons for seeking medical care in Canada. For the MCCQE1, the challenge lies not in diagnosing the obvious viral upper respiratory tract infection (URTI), but in distinguishing self-limiting viral illnesses from bacterial infections requiring antibiotics (specifically Group A Streptococcus) and identifying life-threatening emergencies (like epiglottitis).

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CanMEDS Corner:

  • Medical Expert: Apply clinical decision rules (McIsaac/Centor) to guide appropriate testing and prescribing.
  • Communicator: Effectively explain the rationale for not prescribing antibiotics for viral illnesses (Antibiotic Stewardship).
  • Health Advocate: Promote vaccination (e.g., Influenza, Diphtheria) and hygiene practices.

Differential Diagnosis

The etiology of sore throat and rhinorrhea is predominantly viral. However, a structured approach is necessary to rule out serious pathology.

  • Rhinovirus/Coronavirus/Adenovirus: The “Common Cold.” Associated with coryza, cough, conjunctivitis.
  • Influenza: Sudden onset, systemic symptoms (myalgia, fever).
  • Epstein-Barr Virus (EBV): Infectious Mononucleosis. Posterior cervical lymphadenopathy, hepatosplenomegaly, fatigue.
  • Herpes Simplex Virus (HSV): Gingivostomatitis.
  • Coxsackie Virus: Herpangina (vesicles on soft palate), Hand-Foot-and-Mouth disease.

Clinical Assessment

History Taking

For MCCQE1 case simulations (CDM) or MCQs, focus on these key discriminators:

  • Onset: Sudden (Bacterial/Flu) vs. Gradual (Viral).
  • Associated Symptoms:
    • Viral suggestions: Cough, coryza (runny nose), conjunctivitis, diarrhea, hoarseness.
    • Bacterial suggestions: Fever > 38°C, tender anterior cervical adenopathy, absence of cough.
  • Epidemiology: Sick contacts, season (Winter/Spring for GAS), age (5-15 years peak for GAS).

Physical Examination

🚩 Red Flags: Airway Obstruction

Before examining the oropharynx, assess for signs of impending airway compromise. If present, do not agitate the patient (e.g., with a tongue depressor).

  • Stridor
  • Drooling
  • Tripod positioning (leaning forward)
  • “Hot potato” voice
  • Toxic appearance

Standard Exam Findings:

  • Oropharynx: Erythema, exudates (tonsillar), petechiae (palatal), uvular deviation (Peritonsillar abscess).
  • Neck: Lymphadenopathy (Anterior = GAS; Posterior = Mononucleosis).
  • Abdomen: Splenomegaly (Mononucleosis).
  • Skin: Scarlatiniform rash (Sandpaper texture = Scarlet Fever).

The Canadian Approach to Group A Strep (GAS)

In Canada, guidelines emphasize not treating based on clinical suspicion alone. We use decision rules to determine who needs testing.

Modified Centor Score (McIsaac Score)

This is the standard tool used in Canada. It adds an age correction to the original Centor score.

CriteriaPoints
Temperature > 38°C+1
Absence of cough+1
Swollen, tender anterior cervical nodes+1
Tonsillar swelling or exudate+1
Age 3 to 14 years+1
Age 15 to 44 years0
Age ≥ 45 years-1

Management Algorithm

Step 1: Calculate Score

Assess the patient and calculate the McIsaac Score.

Step 2: Determine Action

  • Score 0-1: No culture, no antibiotic. (Risk of GAS < 10%).
  • Score 2-3: Perform Throat Swab (Culture or RADT). Treat only if positive.
  • Score 4-5: Perform Throat Swab. Empiric treatment is controversial; Canadian guidelines generally recommend testing before treating unless the patient is very ill or follow-up is impossible.

Step 3: Testing Methods

  • Rapid Antigen Detection Test (RADT): High specificity, lower sensitivity.
    • If RADT is positive: Treat.
    • If RADT is negative in children/adolescents: Must confirm with culture.
    • If RADT is negative in adults: Generally safe to stop (low risk of rheumatic fever).
  • Throat Culture: The Gold Standard.

Management Strategies

Viral Pharyngitis & Rhinorrhea

  • Mainstay: Supportive care.
  • Analgesia: Acetaminophen or Ibuprofen.
  • Hydration: Essential.
  • Cough/Cold meds: Generally contraindicated in children < 6 years (Health Canada).

Group A Streptococcus (GAS)

The goal is to prevent Rheumatic Fever and reduce transmission.

  • First Line: Penicillin V (oral) for 10 days.
    • Pediatric Note: Amoxicillin is often preferred due to better taste, though Penicillin V is the narrow-spectrum choice.
  • Penicillin Allergy:
    • Non-anaphylactic: Cephalexin.
    • Anaphylactic: Clindamycin or Macrolides (Clarithromycin/Azithromycin) - Note: Resistance to macrolides is increasing.

Infectious Mononucleosis (IM)

  • Cause: Epstein-Barr Virus (EBV).
  • Diagnosis: Monospot test (Heterophile antibodies) or EBV serology.
  • Key Management:
    • Supportive care.
    • Avoid Contact Sports: For at least 3-4 weeks (risk of splenic rupture).
    • Avoid Amoxicillin/Ampicillin: Causes a maculopapular rash in >90% of IM patients (mistaken for penicillin allergy).

Specific High-Yield Conditions for MCCQE1

Epiglottitis

  • Pathogen: Haemophilus influenzae type b (Hib). Rare now due to vaccines.
  • Presentation: “The 4 D’s”: Drooling, Dysphagia, Dysphonia, Distress. Tripod position.
  • X-ray: “Thumb sign” (enlarged epiglottis).
  • Management: Secure the airway (OR intubation). IV antibiotics (Ceftriaxone + Vancomycin).

Peritonsillar Abscess (Quinsy)

  • Presentation: Unilateral severe throat pain, trismus (lockjaw), “hot potato” voice, uvula deviated to the contralateral side.
  • Management: Needle aspiration or Incision & Drainage (I&D) + Antibiotics.

Rhinorrhea Specifics

  • Allergic Rhinitis: Intranasal corticosteroids (fluticasone) are first-line for moderate/severe cases. Antihistamines for mild/intermittent.
  • Vasomotor Rhinitis: Triggered by temperature changes/spicy food. Treatment: Ipratropium bromide nasal spray.
  • Rhinosinusitis:
    • Viral: < 7-10 days.
    • Bacterial: Symptoms > 10 days OR “Double sickening” (better then worse). Treat with Amoxicillin if severe.

Canadian Guidelines & Choosing Wisely

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Choosing Wisely Canada Recommendations:

  1. Don’t use antibiotics for upper respiratory infections that are likely viral (e.g., influenza-like illness, or pharyngitis with a McIsaac score of < 2).
  2. Don’t prescribe antibiotics for acute sinusitis unless symptoms persist for more than 7 days or are severe at onset.

Key Abbreviations

- GAS: Group A Streptococcus
- URTI: Upper Respiratory Tract Infection
- RADT: Rapid Antigen Detection Test
- EBV: Epstein-Barr Virus
- ENT: Ear, Nose, and Throat (Otolaryngology)

Key Points to Remember for MCCQE1

  1. Rheumatic Fever: The primary reason we treat GAS pharyngitis in Canada is to prevent Rheumatic Heart Disease.
  2. Age Matters: GAS is rare in children < 3 years old (usually viral).
  3. The Rash: If you give Amoxicillin to a patient with Mono, they get a rash. It is not an allergy.
  4. Airway First: In any throat complaint, rule out airway obstruction (Stridor/Drooling) first.
  5. Follow-up: Routine post-treatment throat culture is not recommended for asymptomatic patients.

Sample Question

Scenario: A 19-year-old male university student presents to the campus clinic complaining of a severe sore throat and fever for the past 2 days. He reports difficulty swallowing but denies any cough, runny nose, or difficulty breathing. He has no known drug allergies. On examination, his temperature is 38.5°C, HR 90 bpm, and BP 118/76 mmHg. Oropharyngeal exam reveals erythema with tonsillar exudates. There is tender anterior cervical lymphadenopathy. His lungs are clear to auscultation.

Which one of the following is the most appropriate next step in management?

  • A. Prescribe oral Penicillin V immediately
  • B. Perform a Rapid Antigen Detection Test (RADT) and prescribe antibiotics only if positive
  • C. Prescribe oral Azithromycin immediately
  • D. Perform a Monospot test and reassure the patient
  • E. Provide supportive care only and discharge

Explanation

The correct answer is:

  • B. Perform a Rapid Antigen Detection Test (RADT) and prescribe antibiotics only if positive

Detailed Analysis:

  • Step 1: Calculate McIsaac Score.

    • Fever (>38°C): +1
    • Absence of cough: +1
    • Tender anterior cervical nodes: +1
    • Tonsillar exudates: +1
    • Age (15-44): 0
    • Total Score = 4

  • Step 2: Apply Canadian Guidelines.

    • A score of 4 indicates a high probability of Group A Streptococcus (GAS) infection (approx. 40-60%).
    • However, Canadian guidelines (and Choosing Wisely) recommend confirming the diagnosis before treatment to avoid unnecessary antibiotic use and resistance.
    • Therefore, a throat swab (RADT or culture) is indicated.

  • Why other options are incorrect:

    • A & C: Empiric antibiotic treatment is generally discouraged in Canada for stable patients, even with high scores, due to the availability of rapid testing and the need for stewardship.
    • D: While Mononucleosis is a differential (university student), the classic presentation here (high fever, exudates, tender anterior nodes, no cough) strongly suggests GAS first. Monospot might be considered if the Strep test is negative or if symptoms persist.
    • E: With a score of 4, the risk of GAS is too high to dismiss without testing.

References

  1. Anti-infective Guidelines for Community-acquired Infections (Orange Book). Mums Health. Toronto, Canada.
  2. Choosing Wisely Canada. Antibiotic usage in primary care. Link 
  3. Canadian Paediatric Society. Group A streptococcal pharyngitis: A practical guide to diagnosis and treatment.
  4. Medical Council of Canada. MCCQE Part I Objectives: Sore Throat / Rhinorrhea.
  5. Centor RM, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981.
  6. McIsaac WJ, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998.
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LymphadenopathyAcid Base Abnormalities