Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics

Potential efficacy and safety of Xiyanping injection as adjuvant therapy in treatment of suppurative acute tonsillitis: a meta-analysis, trial sequential analysis, and certainty of evidence

Background: Antibiotic resistance has emerged as a global concern. Xiyanping injection (XYP), a traditional Chinese medicine injection, has been extensively utilized for the treatment of suppurative acute tonsillitis (SAT) in China, exhibiting clinical efficacy. Consequently, there is a need for further evaluation of the potential effectiveness and safety of this treatment. This meta-analysis consolidated data from multiple independent studies to assess the overall treatment efficacy of XYP as adjuvant therapy in patients with SAT. Methods: The search for randomized controlled trials (RCTs) encompassed databases from their inception to 1 April 2024, including the Cochrane Library, PubMed, Embase, SinoMed, CNKI, Wanfang, VIP, and CBM. Data extraction, methodological quality assessment, and meta-analysis were performed independently by two researchers. Review Manager 5.4 was used for data analysis. Various tools were employed for assessment, including forest plots to visualize results, funnel plots to detect publication bias, trial sequential analysis to estimate sample size, and GRADE to evaluate evidence quality. Results: A comprehensive analysis of 32 RCTs involving 4,265 cases was conducted. When compared to conventional treatments (CTs; β-lactams/clindamycin hydrochloride injection/ribavirin) alone, the combination of XYP with CTs demonstrated significant reductions in symptom duration. This included sore throat (MD = -21.08, 95% CI: -24.86 to -17.29, p < 0.00001), disappearance of tonsillar redness and swelling (mean difference [MD] = -20.28, 95% confidence interval [CI]: -30.05 to -10.52, p < 0.0001), tonsil purulent discharge (MD = -22.40, 95% CI: -28.04 to -16.75, p < 0.00001), and normalization of temperature (MD = -19.48, 95% CI: -22.49 to -16.47, p < 0.00001). Furthermore, patients receiving CTs combined with XYP exhibited lower levels of interleukin-6 (MD = -7.64, 95% CI: 8.41 to -6.87, p < 0.00001) and interleukin-8 (MD = -5.23, 95% CI: -5.60 to -4.86, p < 0.00001) than those receiving CTs alone. Additionally, the combination therapy significantly improved the recovery rate (relative risk [RR] = 1.55, 95% CI: 1.37 to 1.77, p < 0.00001), white blood cell count recovery rate (RR = 1.13, 95% CI: 1.04 to 1.23, p = 0.004), and disappearance rate of tonsillar redness and swelling (RR = 0.51, 95% CI: 1.14 to 1.38, p < 0.00001), with no significant increase in adverse events (RR = 0.47, 95% CI: 0.20 to 1.10, p = 0.08). Conclusion: The current systematic review and meta-analysis tentatively suggest that the combination of XYP and CTs yields superior clinical outcomes for patients with SAT compared to CTs alone, with a favorable safety profile. Nonetheless, these findings warrant further confirmation through more rigorous RCTs, given the notable heterogeneity and publication bias observed in the included studies. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=296118, identifier CRD42022296118.

Prevalence of Acute Tonsillitis and Its Association With Oral Hygiene Among the Population of Taif City, Saudi Arabia

Introduction  Dental surfaces have dense bacterial deposits, and poor oral hygiene can exacerbate bacterial infections, causing acute tonsillitis. The study aims to quantify acute tonsillitis prevalence and assess its association with oral hygiene practices. Methods  A descriptive cross-sectional study aimed to assess the prevalence of acute tonsillitis and its association with oral hygiene was conducted among adults aged 20 and above in Taif City, Saudi Arabia. Illiterates and those unwilling to participate were excluded. We employed an Arabic online self-administered questionnaire that was disseminated conveniently via Google Forms to social media assessing oral hygiene such as last dental visit, age at starting dental care, number of toothbrushes per day, frequency of toothbrush change, and duration of brushing teeth, and acute tonsillitis characteristics of the participants. Results About 393 participated in the study. Of them, 54% were aged 20-30, 53% were males, and 70% had a university education. The prevalence of acute tonsillitis was 64%. Approximately 28% reported dental clinic visits within three months, and 21% initiated oral hygiene practices at age 20. Among participants, 43% brushed twice daily, with 33% spending one minute and 43% two minutes. About 31% replaced toothbrushes every three months, while 23% acknowledged having bad breath. Experiencing bad breath, changing toothbrushes every three months, and having dental visits within less than three months were associated with having acute tonsillitis (p<0.05). However, regression analysis revealed that experiencing bad breath (OR: 2.11, 95% CI: 1.23, 3.70) was associated with a higher risk of acute tonsillitis, while less frequent toothbrush changes correlated with a lower risk (OR: 0.54, 95% CI: 0.30, 0.94). Conclusion  This study revealed a substantial prevalence of acute tonsillitis among adults in Taif City. Oral care practices need improvement. There are significant associations between oral hygiene practices, bad breath, and the occurrence of acute tonsillitis. Addressing oral hygiene practices could be a key focus for preventative measures.

Forget-me-not: Lemierre's syndrome, a case report

Background: Familiarity breeds complacency. One case of sore throat can start to sound like another. However, even common viral and bacterial infections can lead to serious sequelae. Clinicians cannot make a diagnosis if they do not consider it in their differential.Case: The presentation - and subsequent hospitalization - of a septic 19 year-old male college student is described. Despite brief interval improvement, he became hypoxic one week after developing a sore throat and was ultimately diagnosed with Lemierre's syndrome (septic thrombophlebitis of the internal jugular vein) via blood cultures and advanced imaging.Conclusions: Though rare, Lemierre's syndrome carries a high mortality rate. It should be considered an emergent complication of head and neck infections, particularly in young adults.

Apixaban-Induced Pseudo-Ludwig’s Angina

Ludwig’s angina describes fulminant cellulitis involving the oro- and hypopharynx, which typically stems from bacterial pathogens, whereas “pseudo-Ludwig’s angina” is ascribed to sublingual swelling due to noninfectious causes. There is a paucity of case reports implicating warfarin as the culprit for sublingual hematoma mimicking Ludwig’s angina; however, we describe a novel case of apixaban-induced pseudo-Ludwig’s angina, which was successfully managed with urgent surgical intervention and supportive care with antibiotic and glucocorticoid therapy.

Erythematous rash and postinfectious acral desquamation due to Streptococcus dysgalactiae subspecies equisimilis infection in a child

Streptococcus dysgalactiae subspecies equisimilis infection is an emerging pathogen. Cutaneous and systemic manifestations resemble those of other pyogenic streptococci. However, the rapid group A antigen detection test used to diagnose Streptococcus pyogenes infection is usually negative, making the diagnosis difficult. If clinical suspicion of streptococcal infection is high, a tonsillar culture should be performed to confirm the diagnosis.

Can AI Help Pediatricians? Diagnosing Kawasaki Disease Using DRSA

The DRSA method (dominance-based rough set approach) was used to create decision-making rules based on the results of physical examination and additional laboratory tests in the differential diagnosis of Kawasaki disease (KD), infectious mononucleosis and S. pyogenes pharyngitis in children. The study was conducted retrospectively. The search was based on the ICD-10 (International Classification of Diseases) codes of final diagnosis. Demographic and laboratory data from one Polish hospital (Poznan) were collected. Traditional statistical methods and the DRSA method were applied in data analysis. The algorithm formed 45 decision rules recognizing KD. The rules with the highest sensitivity (number of false negatives equals zero) were based on the presence of conjunctivitis and CRP (C-reactive Protein) ≥ 40.1 mg/L, thrombocytosis and ESR (Erythrocyte Sedimentation Rate) ≥ 77 mm/h; fair general condition and fever ≥ 5 days and rash; fair general condition and fever ≥ 5 days and conjunctivitis; fever ≥ 5 days and rash and CRP ≥ 7.05 mg/L. The DRSA analysis may be helpful in diagnosing KD at an early stage of the disease. It can be used even with a small amount of clinical or laboratory data.

Unusual Site for a White Nodule on the Palatine Tonsil: Presentation, Differential Diagnosis, and Discussion

Introduction

Palatine tonsils are part of the mucosa-associated lymphoid tissue, located in the oropharyngeal region. Although these tissues protect the body from foreign intruders, they are more prone to infections due to their anatomical structure and location. For instance, the differential diagnosis of a white lesion on the palatine tonsil can range from benign to malignant lesions. Oral lymphoepithelial cysts commonly arise as painless, yellowish nodules on the floor of the mouth and the ventral or lateral surface of the tongue. Case Presentation. This paper presents a rare case of an unusual site of a lymphoepithelial cyst (LEC) in the oral cavity. The lesion was located in the tonsil of a 20-year-old woman with a chief complaint of a painless, white lump in the back of the mouth for nine months. Discussion. The differential diagnosis of a white lesion on the palatine tonsil is caused by several factors, such as bacterial, viral, and fungal infections; trauma; stones; cysts; abscess; or cancer. In this case, both the clinical presentation and extra- and intraoral examinations were highly associated with LEC. Oral LEC etiopathogenesis is uncertain, and several theories have been proposed to discuss the causes of LEC. In addition, oral LEC could be monitored without surgical intervention if the nodule is asymptomatic.

Conclusion

We emphasize the importance of a thorough clinical examination of oral and oropharyngeal lesions, which are usually neglected.

Understanding the most commonly billed diagnoses in primary care: Acute pharyngitis

ABSTRACT

This is a 12-part series on the most commonly billed diagnoses in primary care. The article discusses the pathophysiologic processes of acute pharyngitis as well as the clinical manifestations and treatments and how they are linked to disease pathogenesis.

A Symptom-Directed Paradigm for the Evaluation and Management of Upper Respiratory Tract Infections

Upper respiratory tract infections are one of the most common challenges in ambulatory medicine. Effective evaluation involves identification, primarily through the history, of the dominant set of patient symptoms leading to accurate diagnosis. Certain more morbid illnesses that mimic common upper respiratory symptoms can also be excluded with this approach. Treatment should address patient preferences through an understanding of the limited utility of antibiotics and through tailored advisement of the numerous pharmacologic options for symptom relief.

Relieving Sore Throat Formula Exerts a Therapeutic Effect on Pharyngitis through Immunoregulation and NF-κB Pathway

Relieving Sore Throat Formula (RSTF) is a formula approved by the China Food and Drug Administration and has been used for the treatment of pharyngitis in clinic for many years. However, the potential pharmacological mechanism still remains unknown. We combined multiple methods including bioinformatics data digging, network pharmacology analysis, and pathway analysis to predict the potential target of RSTF. We verified our in silico prediction results with an in vivo/vitro antibacterial effect test, mouse phagocytic index test, proliferation, transformation, and migration of mouse spleen lymphocytes. Alteration of NF-κB pathway was determined by Western blotting, immunofluorescence, and PCR. The in vivo experiments demonstrated that the RSTF could significantly relieve the symptoms of pharyngitis. A rat saliva secretion test showed that RSTF can effectively relieve the xerostomia symptom. A phenol red excretion test showed that RSTF has an eliminating phlegm effect. A hot plate method and granuloma experiment proved that RSTF also have analgesic and anti-inflammatory effects. In silico prediction demonstrates that 70 active compounds of RSTF were filtered out through ADME screening and 84 putative targets correlated with different diseases. Pathway enrichment analysis showed that the candidate targets were mostly related to the response to bacteria and immunity signalling pathways, which are known contributors to pharyngitis. Experimental results confirmed that RSTF exerted therapeutic effects on pharyngitis mainly by antibacterial effect and downregulation of NF-κB activities. It is demonstrated both in silico and in vivo/vitro that RSTF exerted therapeutic effects on pharyngitis mainly through an antibiotic effect and downregulation of NF-κB signalling pathway.

Volatile scents of influenza A and S. pyogenes (co-)infected cells

Influenza A is a serious pathogen itself, but often leads to dangerous co-infections in combination with bacterial species such as Streptococcus pyogenes. In comparison to classical biochemical methods, analysis of volatile organic compounds (VOCs) in headspace above cultures can enable destruction free monitoring of metabolic processes in vitro. Thus, volatile biomarkers emitted from biological cell cultures and pathogens could serve for monitoring of infection processes in vitro. In this study we analysed VOCs from headspace above (co)-infected human cells by using a customized sampling system. For investigating the influenza A mono-infection and the viral-bacterial co-infection in vitro, we analysed VOCs from Detroit cells inoculated with influenza A virus and S. pyogenes by means of needle-trap micro-extraction (NTME) and gas chromatography mass spectrometry (GC-MS). Besides the determination of microbiological data such as cell count, cytokines, virus load and bacterial load, emissions from cell medium, uninfected cells and bacteria mono-infected cells were analysed. Significant differences in emitted VOC concentrations were identified between non-infected and infected cells. After inoculation with S. pyogenes, bacterial infection was mirrored by increased emissions of acetaldehyde and propanal. N-propyl acetate was linked to viral infection. Non-destructive monitoring of infections by means of VOC analysis may open a new window for infection research and clinical applications. VOC analysis could enable early recognition of pathogen presence and in-depth understanding of their etiopathology.

Infections of the Oropharynx

This article reviews the presentation, diagnosis, and management of common and "can't miss" infections of the oropharynx, including streptococcal pharyngitis, infectious mononucleosis, peritonsillar abscess, retropharyngeal abscess, and epiglottitis.