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A New Consideration for Sore Throats

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Physician's First Watch for December 1, 2009
David G. Fairchild, MD, MPH, Editor-in-Chief

Commentary Urges 'Expanding the Diagnostic Paradigm of Pharyngitis' in Young People

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WHO Updates HIV Guidelines

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Commentary Urges 'Expanding the Diagnostic Paradigm of Pharyngitis' in Young People


An Annals of Internal Medicine commentator urges that clinicians change their approach to treating pharyngitis in adolescents and young adults. He argues that Fusobacterium necrophorum is more likely to cause severe complications than group A beta-hemolytic strep is to cause rheumatic fever.


Using available data, the commentator, Dr. Robert Centor, estimates that both organisms are equally likely to cause pharyngitis in young people between the ages of 15 and 24. Of greatest concern is the association between fusobacterium infection and Lemierre syndrome, which has a mortality rate of nearly 5%.


When physicians treat pharyngitis empirically in young people, he argues, macrolides should no longer be used, since they are ineffective against fusobacterium. Instead, penicillins or cephalosporins should be used until a better way of diagnosing fusobacterium infections is found.


Annals of Internal Medicine perspective (Free abstract; full text requires subscription)

Video of Dr. Robert Centor talking about pharyngitis and fusobacterium infection (Free)

Perspectives
Expand the Pharyngitis Paradigm for Adolescents and Young Adults
Robert M. Centor, MD
+ Author Affiliations

From the University of Alabama at Birmingham, Huntsville, Alabama.
Abstract
Current guidelines and review articles emphasize that clinicians should consider group A ?-hemolytic streptococcus in the diagnosis and management of patients with acute pharyngitis. Recent data suggest that in adolescents and young adults (persons aged 15 to 24 years), Fusobacterium necrophorum causes endemic pharyngitis at a rate similar to that of group A ?-hemolytic streptococcus. On the basis of published epidemiologic data, F. necrophorum is estimated to cause the Lemierre syndrome—a life-threatening suppurative complication—at a higher incidence than that at which group A streptococcus causes acute rheumatic fever. Moreover, these estimates suggest greater morbidity and mortality from the Lemierre syndrome. The diagnostic paradigm for adolescent pharyngitis should therefore be expanded to consider F. necrophorum in addition to group A streptococcus. Expanding the pharyngitis paradigm will have several important implications. Further epidemiologic research is needed on both F. necrophorum pharyngitis (especially clinical presentation) and the Lemierre syndrome. Clinicians need reliable diagnostic techniques for F. necrophorum pharyngitis. In the meantime, adolescents and young adults who develop bacteremic symptoms should be aggressively treated with antibiotics for F. necrophorum infection. Physicians should avoid macrolides if they choose to treat streptococcus-negative pharyngitis empirically. Finally, pediatricians, internists, family physicians, and emergency department physicians should know the red flags for adolescent and young adult pharyngitis: worsening symptoms or neck swelling (especially unilateral neck swelling). Adolescent and young adult pharyngitis is more complicated than previously considered.

Article and Author Information
Potential Conflicts of Interest: None disclosed.
Requests for Single Reprints: Robert M. Centor, MD, Huntsville Regional Medical Campus, University of Alabama at Birmingham, 301 Governors Drive, Huntsville, AL 35801; e-mail, rcentor@uab.edu.

Annals of Internal Medicine December 1, 2009
vol. 151 no. 11 812-815

Fusobacterium necrophorum is a well established cause of Lemierre's disease (LD); a syndrome characterised by severe sore throat, septicaemia, multiple abscesses and jugular vein thrombosis. There is no published data concerning the role of F. necrophorum in recurrent sore throats. As the result of an index case of persistent sore throat attributable to this organism being diagnosed in our laboratory, a subsequent case controlled study (not yet published) isolated F. necrophorum from 21% (P=0.0001) of cases of persistent, recurrent and chronic sore throats. The object of this study was to compare isolates of F. necrophorum from cases of systemic disease with isolates from cases of persistent sore throat syndrome (PSTS) to ascertain whether strains of similar type were responsible for both throat and systemic disease or whether different strains were involved in these presentations.

Methods
Throat swabs were cultured on GN anaerobe medium (Oxoid) and incubated at 37°C for 5 days. Seventeen PSTS isolates were identified phenotypically. These were compared to 17 strains isolated from blood cultures which were referred to the Anaerobe Reference Unit, (ARU) cardiff, using enterogenic repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR). The control strains Fusobacterium necrophorum ssp. necrophorum (JCM 3718T) and Fusobacterium necrophorum ssp. funduliforme (JCM 3724T) from the Japanese Collection of Microrganisms (JCM) were tested in parallel with the clinical isolates.

Results
At least 12 separate types were identified. Four of 17 PSTS isolates and seven of 17 blood culture isolates grouped together with the F. necrophorum ssp. funduliforme control strain. There were also similarities between other proposed strains and clinical types but no comparison with the F. necrophorum ssp. necrophorum control.

Conclusion
These results show that clinical disease caused by F. necrophorum has a wider spectrum than first anticipated. Similar strains are able to cause either chronic local or acute systemic disease suggesting that genetic factors such as those relating to major histocompatibility complex (MHC) class may be influencing the outcome of the disease in each patient. Further work is required to produce a more accurate typing scheme and to ascertain the mechanisms of disease caused by this organism.

An age correlation between the high risk groups for onset of infectious mononucleosis (IM), peritonsillar abscess (PTA), LD and PSTS has been noted in adolescents and young adults. Further work is required to investigate whether IM is associated with the onset of PTA caused by F. necrophorum which may lead to either PSTS or LD.

CLINICAL MANIFESTATIONS

Fusobacterium species may colonize humans and animals. Fusobacterium necrophorum and Fusobacterium nucleatum can be isolated from oropharyngeal specimens in healthy people, are frequent components of human dental plaque, and may lead to periodontal disease. Invasive disease attributable to Fusobacterium species has been reported following otitis media, tonsillitis, gingivitis, and oropharyngeal trauma. Ten percent of published cases of invasive Fusobacterium infections are associated with Epstein-Barr virus infection.

Invasive infection with Fusobacterium species can lead to life-threatening disease. Otogenic infection is the most frequent primary source in children younger than 5 years of age and can be complicated by meningitis and thrombosis of the dural venous sinuses. Invasive infection following tonsillitis was described in the early 20th century and classically was referred to as postanginal sepsis or Lemierre disease. Lemierre disease occurs most commonly in adolescents and young adults and includes internal jugular vein thrombophlebitis or thrombosis (JVT), evidence of septic embolic lesions in lungs or other sterile sites, and usually isolation of Fusobacterium species from blood or other normally sterile sites. Fever and sore throat are followed by severe neck pain (anginal pain) that can be accompanied by unilateral neck swelling, trismus, and dysphagia. People with classic Lemierre disease have a sepsis syndrome with multiple organ dysfunction, disseminated intravascular coagulation, empyema, pyogenic arthritis, or osteomyelitis. Persistent headache or other neurologic signs may indicate the presence of cerebral venous sinus thrombosis (eg, cavernous sinus thrombosis) or meningitis or brain abscess.


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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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