ACUTE RESPIRATORY INFECTIONS

EKUNSUMI .A.A
FWACP
 INTRODUCTION
• A substantial number of visits to the
pediatrician is due to upper respiratory tract
infection and about 40% presents with sore
throat or evidence of pharyngitis on
examination1.
• Worldwide an estimated 616 million cases of
pharyngitis are caused by GABHS(Group A β
Hemolytic streptococcus) annually

• 1. Ralph F. Wetmore. Tonsils and Adenoids In Kliegman R, Behrman RE, Jenson HB, Stanton BF (eds), Nelson Textbook of Paediatrics.19 th
Edition 2012;Pages 1058-1060

02/06/2025
 EPIDEMIOLOGY
• Viruses predominate as acute infectious causes of
pharyngitis1.
• Most children and adults experience 3-5 viral URTI
(including pharyngitis) per year. Rhinovirus cause
approximately 20% of cases of pharyngitis2
• Between viruses Rhinovirus, Coronavirus and
Adenovirus account for the 30% of the total cases,
Epstein Barr virus for 1%, Influenza and Parainfluenza
virus for about 4%3

• 1. Ralph F. Wetmore. Tonsils and Adenoids In Kliegman R, Behrman RE, Jenson HB, Stanton BF (eds), Nelson Textbook of
Paediatrics.19th Edition 2012;Pages 1058-1060
2.Koko Aung , MD, MPH, FACP; medscape; viral pharyngitis; jul 24, 2017
• 02/06/2025
3. Marta Regoli*, Elena Chiappini, Francesca Bonsignori, Luisa Galli, Maurizio de Martino*; Update on the management of acute pharyngitis
• in children; italian journal 2011
 EPIDEMIOLOGY (CONTD)

• Transmission occurs most commonly in fall,

winter, rainy season and spring.
• GABHS is the most important bacterial cause
of acute pharyngitis and Tonsillitis1.
• Streptococcal pharyngitis is relatively
uncommon before 2-3 yr of age, has a peak
incidence in the early school years, and
declines in late adolescence and adulthood1.

02/06/2025
 DEFINITION
• ARI is defined as a heterogeneous and complex
group of clinical entities in which the possible
anatomic site(s) affected extend from the Pharynx to
the alveoli.
• Acute Pharyngitis refers to an acute inflammatory
lesion in which the primary site of the pathology is
the pharynx, the tonsils inclusive.
• Sore throat, pharyngeal tonsillar inflammation with
or without exudates remain the cardinal
manifestations.
 RISK FACTORS
• Demographic factors : age , male gender
• Host factors : Malnutrition
– non/partial immunisation status
– non exclusive breast feeding
– vitamin A,D and Zinc defficiency
– underlying atopy
• Low socioeconomic status
• Overcrowding
• Poor housing
• Low birthweight infants
 CLASSIFICATION
• Aetiology
– Infectious
– Non infectious
• Duration
– Acute
– Chronic
– Recurrent
• Anatomic
– Exudative
– Ulcerative
– Membranous

– 5. Murray RC, Chennupati SK (2012); chronic streptococcal and non streptococcal pharyngitis
02/06/2025
 AETIOLOGY

• Infectious
– Viral
– Bacterial
– Fungi
• Non infectious
– GERD
– Burn pharyngitis
– Radiation damage
– Leukemia
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 AETIOLOGY
• Infectious Agents That Cause Pharyngitis1
VIRAL BACTERIAL
Rhinovirus GABHS
Coronavirus Staph . Aureus
Adenovirus K. pneumonia
Influenza Fusobacterium necrophorum
Parainfluenza Francisella tularensis
Epstein Barr virus Corynbacterium diphtheria
HSV Group C streptococci
Enteroviruses Group G streptococci
Respiratory syncytial virus Arcanobacterium hemolyticum
HIV Chlamydophilia pneumonia
Human metapneumovirus
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Neisseria gonorrhoeae
 PHARYNGITIS
• Differences in the presenting features of viral
and bacterial pharyngitis1
VIRAL BACTERIAL AETIOLOGY

Insiduos onset Rapid/sudden onset

Rhinorrhoea Prominent sore throat

Conjunctivitis Fever

Diarrhoea Absence of cough

Coryza, hoarseness

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 ANATOMY OF THE TONSILS
• Waldeyer ring consists of lymphoid tissue that surrounds the
opening of the oral and nasal cavities into the pharynx and
includes the palatine tonsils, the pharyngeal tonsil or adenoid,
lymphoid tissue surrounding the eustachian tube orifice in the
lateral walls of the nasopharynx, the lingual tonsil at the base
of the tongue, and scattered lymphoid tissue throughout the
remainder of the pharynx but especially behind the posterior
pharyngeal pillars and along the posterior pharyngeal wall.
• Lymphoid tissue located between the palatoglossal fold
(anterior tonsillar pillar) and the palatopharyngeal fold
(posterior tonsillar pillar) forms the palatine tonsil.
 FUNCTIONS
• Approximately 65% of the lymphocytes that make up
the lymphoid tissue of Waldeyer ring are B
lymphocytes, the remainder being either T
lymphocytes or plasma cells.
• The immunologic role of the tonsils and adenoid is to
induce secretory immunity and to regulate the
production of the secretory immunoglobulins.
• Situated at the opening of the pharynx to the external
environment, the tonsils and adenoid are in a position
to provide primary defense against foreign matter
 CHRONIC INFECTION
• The tonsils and adenoid can be chronically
infected by multiple microbes, which may
include a high incidence of β-lactamase–
producing organisms. Both aerobic species,
such as streptococci and Haemophilus
influenzae, and anaerobic species, such as
Peptostreptococcus, Prevotella, and
Fusobacterium, predominate
 PATHOGENESIS
• Mode of transmission includes inhalation and
acquisition of aerosolised pathogen infected droplets
• Unintended self innoculation of the nasal, oral or
conjunctival mucosae.
• Pathogen initiated causes disruption of the well
organised specific and non specific immunological
defense mechanisms
• Pathogen invasion of the respiratory mucosae then
occurs
• Multiplication and seedings of the tissues occur
 PATHOGENESIS CONTD
• Pathogenecity of B-hemolytic streptococcus is
determined by the presence and the amount
of specific cell wall surface antigens called the
M-protein.
• Inflammatory cytokines are activated and
these are responsible for the majority of
symptoms and signs associated with
Pharyngitis.
 CLINICAL FEATURES
• Symptoms of GABHS infection
– Odynophagia
– Dry throat
– Malaise, fever and chills
– Referred otalgia, headache, muscular aches, and
enlarged cervical nodes.
– SIGNS : Dry tongue, erythematous enlarged tonsils,
tonsillar or pharyngeal exudate, palatine petechiae,
and enlargement and tenderness of the
jugulodigastric lymph nodes
 Grading of tonsils enlargement

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 CLINICAL FEATURES CONTD
• Chronic infection:
– Chronic sore throats
– Foreign body sensation
– Hx of expelling foul tasting and smelling cheesy
lumps
02/06/2025
• Nelson textbook of paediatrics; 20th
edition; chapter 381

1. Ralph F. Wetmore. Tonsils and Adenoids In Kliegman R, Behrman RE, Jenson HB, Stanton BF
(eds), Nelson Textbook of Paediatrics.19th Edition 2012;Pages 1058-1060
02/06/2025
• 6.JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11

02/06/2025
 EXAMINATION
• PHYSICAL FINDINGS
– Hyperemic tonsils
– Hyperemic pharynx
– Enlarged tonsils graded
– Exudates
– Halitosis
– Tonsiloliths or Debris that can be removed
manually with a cotton tipped applicator or a
water jet
Aetiologic agents Specific findings

GABHS pharynx is red, the tonsils are enlarged and often

covered with a white, grayish, or yellow exudate
that may be blood-tinged. There may be petechiae
or “doughnut” lesions on the soft palate and
posterior pharynx and the uvula may be red and
swollen.“white strawberry tongue” then(“strawberry
tongue”). Enlarged and tender anterior cervical lymph nodes
Fusobacterium necrophorum Lemierre syndrome, fever, sore throat, exudative pharyngitis
and/or peritonsillar abscess.

Corynebacterium diphtheriae bull neck (extreme neck swelling) and a gray pharyngeal
pseudomembrane

Francisella tularensis Severe throat pain, tonsillitis, cervical adenitis, oral

ulcerations, and a pseudomembrane

Candida albicans White patches on oral mucosae, difficult to remove when

scraped and leave behind an inflamed base that is painful and
bleed.
1. Ralph F. Wetmore. Tonsils and Adenoids In Kliegman R, Behrman RE, Jenson HB, Stanton BF (eds), Nelson Textbook of
Paediatrics.19th Edition 2012;Pages 1058-1060

02/06/2025
 DIAGNOSIS
• Throat culture remains the imperfect gold
standard
• Rapid tests for Streptococcal antigen
commercial kits, detection is based on
agglutination of strept antigen
• Blood culture : positive blood culture is unusual
• Viral culture; expensive, prolonged and
unavailable
 DIAGNOSIS CONTD
• Polymerase Chain Reaction: sensitive however
limited by costs, paucity of the equipment and
lack of expertise.
• Full blood count: polymorphonuclear
leucocytosis in GABHS disease
• Serological tests e.g ASO, Antihyaluronidase and
anti DNAase Btitres are important for
confirming previous invasive B-hemolytic
streptococcus/GABHS
 TREATMENT
• Antibiotic therapy
– Indications
• symptomatic pharyngitis and a
• positive rapid streptococcal antigen test
• clinical diagnosis of scarlet fever h
• household contact with documented streptococcal
pharyngitis
• past history of acute rheumatic fever, or a recent
history of acute rheumatic fever in a family member.
 TREATMENT
• Amoxycillin at a dose of 50mg/kg/day in three
divided doses at a duration of not less than 1
week
• Oral Penicillin V at 12.5mg/kg 6hrly or
25mg/kg 12 hrly for a duration of 10 days
• Single I.m dose of Benzathine Penicillin at
600,000 I.U in <27kg and 1.2 million units in
bigger children
 TREATMENT
• Penicillin allergy : Erythromycin 40-60mg/kg/day 6
hourly or Azithromycin 10mg/kg once daily dosing
for 3-4 days
• Chronic tonsillitis
– Cephalosporins
– Clindamycin
SURGICAL TREATMENT
Tonsillectomy; indications sleep disordered breathing,
failure to thrive, resistant cases of cryptic Tonsillitis,
biopsy
 TREATMENT CONTD
• Elective Tonsillectomy in children
– With seven episodes in one year
– Five episodes in each of the preceding two years
– Three episodes in each of the preceding three
years
 COMPLICATIONS
• Broadly divided into two
– Suppurative/ short term
• Cervical adenitis
• Bacterial sinusitis
• Retropharyngeal abscess
• Otitis media
• Pneumonia
– Non Suppurative
• Post streptococcal glomerulonephritis
• Acute Rheumatic fever
• Rheumatic Carditis