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1. Unit 1:
Diagnosis and Management of
Tonsilo-pharyngitis
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2. Learning Objectives
• Describe the characteristics of Group A Beta
Hemolytic Streptococci
• Describe the epidemiology of GABHS
tonsilopharyngitis
• Explain the difference between viral and GABHS
tonsilopharyngitis
• Outline the diagnostic modality of GABHS tonsilo-
pharyngitis
• Outline the management of GABHS tonsilopharyngitis
• Explain methods of prevention of tonsilopharyngitis
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3. Introduction
• Rheumatic fever is an inflammatory disease involving the
joints, skin, heart and brain, which develops following an
untreated or partially treated group A b-haemolytic
streptococcal (GAS) infection of the throat (streptococcal
pharyngitis).
• Up to 30% of sore throats in children and young people are
caused by GAS, and 0.3% to 3% of young people with an
untreated GAS sore throat will develop RF.
• After recovery from the initial episode of RF, up to 60% to
65% of patients develop valvular heart disease and the risk of
RF recurrence following GAS infection rises to 50%.
• Identification and treatment of bacterial sore throat is an
important component of Rheuamtic Fever/Rheumatic Heart
Disease Prevention and Control Program

4. Tonsilopharyngitis
Sore throat(Tonsilopharyngitis) is a symptom caused by
inflammation of pharynx, tonsils or other surrounding
structures
Viral sorethroat is the predominate cause
 Group A beta hemolytic Streptococci is commonest
bacterial cause
20-40% in children
5-15% of sore throat clinic visits in adults
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5. Group A Beta Hemolytic Streptococci (GABHS)
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• Gram-positive, nonmotile,
non–spore-forming cocci
• 0.5-1.2µm in size. in pairs
or chains
• They are negative for
oxidase and catalase.
• Characterized by local
invasion and release of
extracellular toxins and
proteases

6. Group A Beta Hemolytic Streptococci …
• This organism may cause suppurative disease, such as
pharyngitis, impetigo, cellulitis, myositis, pneumonia, and
puerperal sepsis.
• It also may be associated with nonsuppurative disease, such as
rheumatic fever and Acute Poststreptococcal
Glomerulonephritis.
• Group A streptococci elaborate the cytolytic toxins Streptolysins
S and O.
• Of these, streptolysin O induces persistently high antibody titers
that provide a useful marker of group A streptococcal infection
and its nonsuppurative complications
• M protein fragments of certain serotypes of GABHS are similar
to heart muscle
• Antibodies produced against the bacteria Antigens are affect the
tissue and linked to development heart valve damage.
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7. EPIDEMIOLOGY of GABHS
• Humans are exposed to GABHS in the environment
• Humans are the natural reservoir for GABHS
• Mostly spread through droplets of salivary or nasal
secretions
• Overcrowding , poverty, and close contact with person
with streptococcal sore throat are considered risk
factors for transmission
• The incubation period is 2 to 5 days
• Throat and skin are common sites of GABHS
infection
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8. EPIDEMIOLOGY of GABHS…
• GABHS infections usually resolve without
treatment however if left uuntreated it can lead to
acute rheumatic fever in some people.
• Antibiotic treatment decreases severity of
symptoms and reduces the risk of transmission to
others after 24 hrs of treatment
• Treatment also decreases the risk of acute rheumatic
fever
• Studies show that ARF associated with GABHS
pharyngitis can be prevented if treatment is
commenced within 9 days of symptoms appearing.
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9. Clinical Presentations of Sore Throat
4-1. GABHS pharyngitis
4-2. Viral Pharyngitis
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10. 4-1.GABHS PHARYNGITIS
 Sudden onset of sore throat
 Pain on swallowing and Fever above
380C
 Headache, nausea, vomiting and
abdominal pain
 Tonsilopharyngeal erythema
 Enlarged tonsils with exudate
 Tender and enlarged anterior cervical
lymph nodes (lymphadenitis)
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11. 4.2 VIRAL PHARYNGITIS
• Cough , runny nose conjunctivitis
• Hoarseness, coryza
• Anterior stomatitis, discrete intra-oral
ulcerative lesions
• Exanthema, ,diarrhea
• Absence of fever (strongly suggest)
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12. Bacterial Vs Viral Pharyngitis

13. DIAGNOSIS OF BACTERIAL SORE
THROAT
 The diagnosis of streptococcal pharyngitis
(GABHS) can either be clinical only or using
clinical criteria supported by laboratory
investigations.
 The gold standard diagnostic method is by using a
Clinical Prediction rule (CPR) supported by rapid
antigen test (RAT) and/or throat culture.
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14. THROAT CULTURE
 Not available in all set ups
 Delay in getting results at least 48 hrs.
 Technical errors ( impact on the results)
 Cost of test is high
 Many people are asymptomatic
carriers (10% of school age children).
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15. Rapid Antigen Detection Test for
GABHS
Not available
Not validated in Ethiopia
Expensive
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16. ASO Titer:
NO role in Acute Tonsilopharyngitis
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17. GABHS Diagnosis Clinical Decision Rules (CDR)
Cardinal Clinical features
Symptoms or Signs Points
History of high fever or
(objective record ≥ 38oC)
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Absence of cough and
rhinorrhea
1
Tender anterior Cervical
adenopathy
1
Tonsillar swelling or exudates 1
Clinical Decision Rule
(CDR)
• ≥ 2 points, treat as
GAβHS pharyngitis
(with antibiotic) ,
• < 2 points, treat as
viral pharyngitis (no
antibiotic
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18. Management of Tonsilo-pharyngitis
 Relief of acute symptoms
 Prevention of suppurative and non suppurative
complications
 Reduce communicability
 Pain and fever management (Paracetamol)
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19. Antibiotics for GABHS Treatment
First Line:
Benzathine penicillin ( First Line )
Dose:
Wt. < 30kg:600,000 IU stat.
Wt. > 30 kg:1.2 million IU IM stat.
Use Safe BPG Injection Procedures!
Alternative
Amoxicillin
Dose :
Children < 7years: 50 mg/kg per day in three divided doses for
10 days.
Age>7Years: 500mg PO TID for 10 Days
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20. Antibiotics for GABHS Treatment…
If Patient allergic to penicillin:
ERYTHROMYCIN
Dose
• Less than 7 years: 250 mg BD for 10 days
• More than 7 years: 500 mg BD for 10 days
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21. Why Benzathine Penicillin?
• Single injection
• Better bactericidal effect than oral
• Oral treatment needs 10 whole days to be effective
• Oral macrolides: clinical improvement but no eradication
of organism.
• Cost effective, evidence based.
• Parents and patients more satisfied.

22. Is it cost-effective to administer BPG for
all cases of suspected strep sore throat?
• An overall protective effect for the use of penicillin against
acute rheumatic fever of 80% with an NNT of 60 children
per year to prevent 1 episode of rheumatic fever.
• Mild hypertension: have to treat 800 people per year to
prevent 1 episode of stroke
• The estimated cost of preventing one case of rheumatic fever
by a single monthly intramuscular injection of penicillin is
US$46
• Valve replacement surgery for 1 case of RHD is at least
US$15, 000
• Cardiac surgery only available in S Africa, Ghana and Egypt

23. Prevention and Health Education
Families should be educated about:
1.The symptoms of GAS pharyngitis.
2 The serious consequences of untreated pharyngitis
i.e. ARF and RHD and the need to consult medical
personnel as early as possible to avoid
complications.
3 The need to avoid pharyngitis by improving house
ventilation and hygiene and avoid crowding.
4. Importance of adherence to a 10 days course of
antibiotics in oral treatment.

24. Case study
W/O Almaz brought her five years old girl Helen to the outpatient
clinic with acute onset of fever, severe throat, pain exacerbated by
swallowing, headache and abdominal pain. No runny nose, no
cough.
Physical examination: Wt. 20 kg, her temperature was 38.30C
axillary, the tonsils were symmetrically enlarged, red with
exudates. She had multiple enlarged painful anterior neck
lymphadenopathies. No other abnormal findings detected.
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25. Questions.
1. What is your clinical diagnosis of Helens’ illness?
2. What tests do you need to reach at a diagnosis?
3. What is the most likely causative organism of her illness?
4. How would you like to treat Helen?
5. Which of the clinical presentation helps you to decide
about the treatment you are going to give?
6. What is the drug of choice (type, dose and route of
administration)?
7. What other additional Advice do you like to give to W/O
Almaz?
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26. Key points
•Group A beta hemolytic streptococcus is one of
the commonest cause of bacterial tonsilo-
pharyngitis.
•Diagnosis should be suspected early and use
clinical decision rule.
•Drug of choice for GABHS is single injection of
Benzathine Penicillin G.
•Families should be educated about identifying
children with sore throat early and contacting
health care workers for
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27. End of Unit 1
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