Some sore throats are VERY serious

1

Category : Medical Rants

Very interesting story appears on the BBC site – Warning over killer throat disease. I have done sore throat research early in my career. This article describes a condition so unusual that I know little about it.

It follows a significant rise in the number of cases of Lemierre’s disease this year.

The disease, which is most common in young adults, can cause serious illness and even death if left untreated.

With this disease patients can go downhill quite quickly

The disease is cause by a bacterium called Fusobacterium necrophorum that normally lives harmlessly in people’s mouths.

However, for reasons unknown to scientists, it can start to attack the body of previously healthy people.

It mostly affects young people between the ages of 16 and 23 and is more common in men.

The disease is rare and affects just a handful of people each year. However, there have been 30 cases so far this year – as much as the total for all of last year.

“Most viral sore throats get better of their own accord in a few days but with this disease patients can go downhill quite quickly.”

Lemierre’s disease starts off as a very sore throat and leads to a fever, swollen glands and a general feeling of being unwell.

The question of which patients need antibiotics for their sore throats actually causes great controversy. Two somewhat conflicting guidelines have appeared in the adult literature over the past two years – Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background printed in the Annals of Internal Medicine a journal of the American College of Physicians (the main internal medicine society) and Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis printed in Clinical Infectious Disease a journal of the Infectious Disease Society of America. Briefly, the ACP guideline recommends treating patients on the basis of clinical symptoms, while the IDSA guidelines wants a positive ‘rapid test” prior to providing antibiotics. The controversy is not surprising when one understands each groups advocacy position.

The internists have focused on patient relief. An excellent study for the BMJ – Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults showed that penicillin can give as much as 2 days relief from the symptoms of sore throat.

In constrast, the IDSA, while considering patient relief, has a much stronger bias towards decreasing unnecessary antibiotics usage. They want stronger proof than clinical symptoms prior to prescribing antibiotics. Given my background in this field, I do plan to write a longer analysis of this conflict and submit that for publication.

This controversy – Diagnosis of Strep Throat in Adults: Are Clinical Criteria Really Good Enough? – points out the problem of guidelines. Any group of experts will have biases influencing their guideline development. Thus, one cannot produce an unbiased guideline. Two respected groups developed guidelines on one small problem – and came to very different conclusions. I could make the strong case for either side. But what perspective should we take? I suspect that most adult generalists (internists and family physicians) will side with the ACP approach – as will I. As a side benefit, we would probably prevent the syndrome which started this rant.

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Comments (1)

I’m a physician in a college health center, so pharyngitis is one of those things I just have to love. In essence, I think we’re just mostly out to lunch on the whole approach.

First, Group C strep can be just as painful and is just as common as Group A, but there’s no rapid test for this one. Does penicillin decrease morbidity with Group C? Maybe, but nobody knows for sure. Why do we treat Group A infections with penicillin? To reduce the likelihood of rheumatic fever. How likely is rheumatic fever to occur in the West? It’s become an incredibly rare complication. Thus,we’re still trying to prevent something that just almost never happens, anymore.

The principle issue is one of comfort, not highly invasive disease. If we just had something great to help with the throat pain and the angst, no antibiotics and minimal testing would be necessary . A Mayo ENT study showed that a single 10mg tablet of dexamethasone gave substantial relief to anyone with a sore throat of any cause. Giving it did not cause any adverse events. We’re conditioned against using systemic steroids in the face of infection, but I wonder if this isn’t actually the most rational approach.