Causes of Pharyngitis Sore Throat in Adults

Causes of sore throat can be mainly divided into two groups as infectious and non-infectious. Those caused by infection can be examined under two main headings as viral and bacterial.

Pharyngitis pharynx region consists of three parts. The nasopharynx (nasal region), oropharynx (the part that can be seen roughly when viewed from the mouth), hypopharynx (the rest of the pharynx above the larynx that cannot be seen directly from the mouth when viewed endoscopically, is the remaining part of the pharynx) Infection and inflammation of any or all of the three parts of the pharynx (inflammatory state) is called pharyngitis. . Infectious pharyngitis in adults is only one of many causes of sore throat. Accurate history taking and careful physical examination for each patient are critical to make the differential diagnosis between diseases.

Which viruses cause pharyngitis?

The most common cause of pharyngitis in adults (30-60%) is self-limiting viral infections that are part of the common cold. Adults catch the common cold two to four times a year on average, and 20% of them apply to a health institution because of signs of illness. Rhinoviruses are the virus that most often causes the common cold. Coronavirus and parainfluenza virus are less frequent causes of colds. Coronavirus can cause a disease defined as severe acute respiratory syndrome (SARS). In this disease, sore throat and runny nose are seen only in 13-25% of patients. Throat dryness is observed rather than redness and swelling in the throat. Lymphadenopathy (swelling of lymph nodes) is not seen.

             Rhinoviruses They are transmitted by respiratory tract in the form of droplet infection with large particles. This group of viruses causes inflammation without causing destruction (invasion) in the covering covering the inner surface of the nose. Some inflammatory mediators secreted cause edema and redness in the nasal lining, and this redness swelling progresses down to the pharynx. This infection may present with findings similar to beta infection of the throat, but in rhinovirus infections, the sore throat is not that severe and there is no difficulty in swallowing. Patients usually complain of runny nose, nasal congestion, dry cough, hoarseness, low-grade fever. Treatment of the common cold is symptomatic, and rest and adequate oral fluid intake are sufficient. Sometimes a number of combined cold medicines can be used. It heals in a week in healthy adults. Antibiotics are not used, but if secondary bacterial sinusitis (0.5-5%) develops, antibiotics should be used.

Influenza viruses reach the respiratory tract by droplet infection.

They attack the lining (mucosa) that covers the respiratory system. In case of progression, they can involve the entire respiratory system up to the lungs. It is more common in late autumn and winter. It can cause global epidemics. In cases where it is progressive, it can result in death. Influenza A is more disease-causing and lethal. It can cause illness to hospitalization in very young patients, and the rate of encountering complications is high in patients over 50 years of age. When there is an underlying disease (immuno-suppressed conditions, heart-lung diseases, diabetes) the risk of encountering complications increases. The cause of death due to the disease is usually

It occurs as a result of pneumonia due to primary viral or secondary bacterial infection. It starts with complaints of sudden fever, headache and myalgia (muscle aches). It then continues with complaints of sore throat, malaise, chills, sweating, dry cough and runny nose. Lymphadenopathy (swelling of the lymph nodes) is not seen. The findings usually regress within 3-5 days. Antiviral (zanamivir, oseltamivir) drugs can be used in severe cases and in high-risk groups for complications. If this group of drugs is started within the first 2 days, a regression is observed in the symptoms in the following 2 days. Treatment should be planned according to each patient. The best preventative method is vaccination. The effectiveness of vaccines is between 70-100%. Vaccination is recommended for those with chronic heart-lung diseases, metabolic diseases, immunodeficiency, those who are in the 2nd and 3rd trimesters of pregnancy during the flu season, healthcare personnel, and those who give home care to high-risk patients.

Human Immunodeficiecy Virus(HIV):

Acute HIV infection may occur within days or weeks of exposure, with a mononucleosis-like picture of 40-90%. This febrile condition has been termed acute retroviral syndrome. This is often overlooked, even in people at high risk of HIV, due to the nonspecificity of symptoms. Therefore, acute retroviral syndrome should be kept in mind for differential diagnosis in patients with fever of unknown origin. The most common symptoms are fever, lethargy, skin rash, muscle pain, headache, pharyngitis, swelling of the lymph nodes in the neck region and joint pain. Pharyngitis is seen in 50-70% of patients.

Ulcerated lesions in the mouth and candidiasis (thrush) in the mouth can be seen. Diagnosis can be reached with various blood tests. Ulcers in the mouth in AIDS patients may be due to herpes virus, cytomegalovirus, cryptococcus, histoplasmosis, mycobacterial infection. Ulcers in the mouth are growing, damaging and very painful. It is usually seen in the cavity of the tonsils, floor of the mouth and epiglottis.

Adenovirus:

It is well known that adenoviruses cause pharyngitis (pharyngoconjunctival fever) together with conjunctivitis in children. Adenovirus 3,4.7 and 21 serotypes can cause an outbreak of febrile respiratory system disease in recruits (in situations where a crowded environment is shared). It can cause disease in immunocompromised patients and rarely in healthy adults. Adenoviruses cause pharyngitis, which is part of the febrile respiratory disease in adults. Sore throat is seen in 71% of patients. Adenoviruses directly attack the lining of the pharynx and cause cellular damage. This is why sore throat is more severe than with a cold.

Nasal congestion, dry cough, muscle pain, headache, nausea, vomiting and diarrhea can be seen along with sore throat. The disease mostly goes away on its own, its treatment is symptomatic. The average period of regression of the findings is 10 days. Significant disease can be a cause of death, especially in immunocompromised individuals, and rarely in healthy adults. Adenovirus infections can cause pneumonia, secondary bacterial infections. Quite rarely; They can cause meningitis, encephalitis, cystitis, nephritis, colitis and death.

Epstein-Barr virus (EBV):

This virus remains hidden in the human body. They multiply intermittently, especially in B-lymphocytes and oropharyngeal mucosal cells. Contagion can be transmitted by saliva. Although it is quite rare, another mode of transmission is blood transfusion. Around the world, 80-90% of the population has encountered this virus. Almost all children in developing countries encounter this virus in the first 6 years of life and become immune. In developed countries, 30% of the population encounters this virus in adolescence or adulthood. 50% of this group are infected and become immune without showing any signs of disease. EBV is the virus that causes Infectious Mononucleosis. The initial route of this infection is lymphoid tissues and pharyngeal epithelial cells. The incubation period is 3-7 weeks. Initially malaise, fever chills symptoms are followed 1-2 weeks later by sore throat, fever, loss of appetite and lymphadenopathy (swelling of lymph nodes). Sore throat is seen in 82% of patients and is the most common complaint. In addition to these, abdominal pain, headache, neck stiffness and skin rashes can be seen. On examination, white membrane, redness and swelling of the tonsils in the pharynx region, petechiae at the junction of the soft-hard palate, ulcers in the pharynx and epiglottis are observed. Swelling of the lymph nodes in the neck region is a prominent finding. Enlarged spleen and liver enlargement may be seen. Swelling around the eyes can be seen in 30% of patients.

Atypical lymphocytosis is seen on blood test. Neutropenia (decreased number of blood cells, which is an important element of the immune system), thrombocytopenia (decrease in the number of blood platelets that cause clotting) and asymptomatic elevation in liver function tests can be seen. Diagnosis is made by blood tests. It is mostly a self-limiting disease, but it can cause some complications. These; secondary bacterial infections (especially beta infection of the throat), upper respiratory tract obstruction due to progressive swelling of lymphoid tissue, hepatitis (liver infection, jaundice, ascites, liver failure (rare) Serious neurological complications can be seen in 1-5% of patients. meningitis, encephalitis, neuropathies affecting the cranial nerves, transverse myelitis and Gullian_Barre syndrome.

Spleen rupture, hemolytic anemia, myocarditis, and psychosis are other rare complications that may occur due to infectious mononucleosis. The treatment consists of supportive treatment, rest, reduction of fever and relief of pain. If there is an enlarged spleen, patients should be warned to avoid contact sports before it is seen that this situation improves on ultrasonography. Antivirals won’t work unless there’s a complication. Amoxicillin and ampicillin group antibiotics should not be used in this disease because they cause skin rash. If there is a secondary bacterial infection, another group of antibiotics should be used.

Herpes Simplex Virus(HSV):

are of two types. HSV_1 usually causes disease in the head and neck region. Although HSV-2 mostly causes disease in the genital region, it can also cause disease in the head and neck region. Direct contact of oral secretions is the transmission route of HSV-1. It typically causes pharyngitis. This may or may not be accompanied by gigivostomatitis (gum disease). Recurrent herpes is a reactivation of HSV infection rather than a new infection. It can cause sore throat, fever, malaise and swollen lymph nodes. A painful ulcerated lesion may be seen in the mouth and pharynx. It passes by itself. Antiviral drugs can be used if it causes advanced disease and the patient has an underlying disease. pharyngitis sore throat

What bacteria cause pharyngitis?

Bacteria cause 5-10% of pharyngitis, one of the common causes of sore throat in adults. Bacterial pharyngitis is more common in children (30-40%). Antibiotics may have been prescribed to 75% of adult patients with sore throat, a very small part of the cause of sore throat is bacterial infections, so it will work for very few of this patient group. One of the reasons forcing the physician to this is patient expectation and the other is the physician’s concern that the patient will come back if antibiotics are not prescribed. . Inappropriate use of antibiotics will not only negatively affect the health of the individual, but also negatively affect public health in the coming years.

Group Ab Hemolytic Streptococcus Pyogenes:

It is a throat infection known as beta among the people. It is the most common cause of sore throat and pharyngitis. However, it accounts for only 10% of all pharyngitis infections in the adult population. Its main reservoir is the skin, the mucosa of the upper aerodigestive tract, the nasal region and parts of the oropharynx. It only infects humans. Less than 5% of adults can be found as carriers without symptoms. It is transmitted by breathing in small droplets suspended in the air. It is transmitted less frequently by direct contact. Very rarely, it is transmitted by eating unpasteurized milk and contaminated food.

Infection is more common in autumn and winter. The tonsils, uvula, soft palate, and posterior wall of the pharynx are the affected areas. Symptoms begin suddenly and include severe sore throat, pain in swallowing, swelling of lymph nodes in the neck region, fever, chills, weakness, headache, moderate neck stiffness, and loss of appetite. Hoarseness, cough, conjunctivitis, diarrhea, runny nose and ulcerated lesions are usually absent. In the pharynx area, redness, swelling and symmetrical gray-white membrane are seen on the tonsils. Petechiae may be seen on the soft palate.

The tonsils are usually swollen and there is bad breath.

Skin rashes may be seen. If left untreated, it usually goes away on its own in 3-7 days. Patients are contagious in case of acute infection and for the following week. Antibiotic treatment shortens the duration of symptoms. Initiating antibiotic therapy within the first 24-48 hours reduces the symptoms and contagiousness and also prevents possible complications. If antibiotics are started within the first ten days, protection from acute cardiac rheumatism can be achieved. However, starting antibiotics early does not reduce the incidence of acute post-streptococcal glomerulonephritis (kidney disease that can develop after this group of bacteria, kidney rheumatism). Other possible complications are scarlet fever, toxic shock syndrome, necrotizing fasciitis, and spread of bacteria to distant organs. An algorithm is used when planning treatment. In this algorithm, fever, swelling of the lymph nodes in the anterior region of the neck, membrane over the tonsils, and absence of cough are taken into account. Depending on how many of these findings are present, rapid antigen test, culture or empirical antibiotic treatment is planned.

Group C,G b- hemolytic streptococcal infections:

This group of bacteria is part of the normal throat flora. This group of bacteria can cause acute pharyngitis and is difficult to distinguish from group A b-hemolytic bacteria. Acute glomerulonephritis (kidney rheumatism) can be seen after pharyngitis formed by this group, but they do not cause acute cardiac rheumatism. They are treated with the appropriate group of antibiotics.

Arcanobacterium Hemolyticum:

It is a b-hemolytic bacterium that causes 0.5-2.5% of bacterial pharyngitis. This organism can cause infections such as pneumonia (pneumonia), meningitis (inflammation of the meninges), osteomyelitis (inflammation of the bone), brain abscess and peritonsillar abscess (abscess around the tonsils). . In these complications, the source is often tonsils, skin wounds, or the source may not be detected. It is transmitted through airborne droplets (breathing). This bacterium is not found in the normal throat flora. The bacterium that causes pharyngitis in 2.5% of patients aged 15-18 is Arcanobacterium Hemolyticum.

Symptoms of the disease may be moderate signs of pharyngitis, a white membrane may be seen on the tonsils, or a diphtheria-like illness may occur. Or it can cause septicemia where the infection mixes into the blood. Various forms of skin rash are seen in 25-50% of patients. Skin rashes occur on the trunk, arms and legs, but are not seen on the palms, soles and face. Sometimes skin rashes may be the only manifestation of the disease. In addition, fever and swelling of the lymph nodes can be seen. Diagnosis is made by throat culture. The first-line antibiotic of choice is the Erythromycin group.

Neisseria Gonorrhoeae:

It is a sexually transmitted bacterium. While it causes disease mostly in the anal and genital area, it can also cause gingivitis (gum disease), stomatitis (oral disease), glossitis (tongue-related disease) and pharyngitis infections. Pharyngitis caused by this bacterium is infrequent but well described. It is usually accompanied by genital infection findings, but it can also be only in the affected area. Oral sex is a high-risk behavior for this infection, which is why it is common in women and gay men. In the same person, the infection in the genital area can also be transmitted to the oropharynx area.

It can spread from the throat area to the joints and cause septic arthritis. It can also spread to the skin and cause an infection. It presents with signs of tonsillitis. There is swelling, enlargement and a yellow-white membrane on the tonsils. Trauma-related lesion can be seen on the soft palate and uvula. Fever and swelling of the lymph nodes are not usually seen. The diagnosis is made by producing the material taken from the throat with the appropriate method in the appropriate culture medium. It is treated with a single dose of intramuscular ceftriaxone. There are alternative antibiotic applications to this. Clamydia trachomatis infection is also present in 45% of the cases in which this bacterium is detected, so Clamydia treatment should be given to all detected cases.

Troponema Pallidum (Syphilis):

It is the bacterium that causes the disease known as gonorrhea among the people. In the presence of a risk factor such as orogenital contact, the first sign of primary syphilis can be seen in the mouth region. The most common finding is an ulcerated lesion on the lip. This ulcer can also be seen in the tongue and tonsils, in order of frequency. In the primary stage, mouth involvement is painless and the lesion is not seen in the pharynx. If untreated, it can remain latent (silent) for up to 6 months. Then the secondary syphilis stage begins. Systemic findings are seen in secondary syphilis, but mouth-throat region complaints may also be present. Headache, malaise, fever, sore throat, runny nose, neck mass and skin rash symptoms can be seen. On examination, oval, red colored, mottled bumps or patchy changes in the throat may be seen.

These lesions contain bacteria and are highly contagious. The tonsils may be enlarged on one or both sides and may be red. Painless lymph node swellings can be seen on the neck and other parts of the body. Nonpruritic bumps or mottled bumps on the soles and palms of the feet are typical findings for secondary syphilis. The signs and symptoms of secondary syphilis disappear between 3 and 12 weeks. If it is not treated at this stage, the disease goes back to the latent (silent) phase. Again, at this stage, one third of those who are not treated recover, one third passes into the latent phase (the disease has no signs and symptoms, but there is serological positivity in the blood), and the remaining one third turns into tertiary syphilis. In the secondary syphilis stage, the diagnosis is made microscopically and serologically. Primary and secondary syphilis are treated with a single dose of intramuscular (intramuscular) Benzathine penicillin G.

Chlamydia pneumoniae:

The reservoir is only people. Characteristic of this infection is a prolonged subclinical disease state. It is transmitted by respiratory droplet infection. It usually causes pneumonia and bronchitis in adults. It manifests itself with the complaints of sore throat and hoarseness. It rarely causes pharyngitis without affecting the lower respiratory tract. It is quite difficult to diagnose. Appropriate group antibiotics are used in its treatment.

Mycoplasma pneumoniae:

This bacterium is the causative agent in 15-20% of community-acquired pneumonias. The majority of the population affected by the disease is between the ages of 15-19. From isolated pharyngitis does not do. It is seen as a pneumonia (pneumonia) accompanying sore throat, nasal congestion and cold. Cough, fever, chills, and skin rash are other symptoms that may occur. Involvement of other organs can result in severe illness and death. Steven-Johnson syndrome, emolytic anemia, disseminated intravascular coagulation, pericarditis, myocarditis, meningitis, transverse myelitis and Guillian-Barre syndrome are other conditions that can be seen together. Diagnosis is made with the clinical picture, blood tests and chest X-ray and treated with the appropriate antibiotic group.

Mycobacterium Tuberculosis:

Reactivation of tuberculosis in the endemic population may rarely occur in the tonsils with or without lung involvement. If there is involvement of the tonsils, sore throat and swelling of the lymph nodes are also seen. On examination, it is observed that the tonsils are enlarged and there are ulcers and white membranes on them. In suspected cases, the differential diagnosis of sarcoidosis must be made.

Francisella Tularensis:

It is the causative microorganism of the disease called tularemia. It can be seen as a single case, or it can affect the population in a region. This organism is of animal origin. This organism survives in the bodies of rodents, ticks, raccoons, rabbits, calves, cats and dogs. Ticks are the primary reservoir. Arthropods suck blood from the source animal and are transmitted to humans through contaminated water, food, and respiration through the feces of these arthropods. Human-to-human transmission is rare. It causes three kinds of diseases. Glandular, ulceroglandular and oropharyngeal. 75% of patients are over the age of 15. If the source of contamination is food and water, it can often be seen in more than one person in the family. The oropharyngeal form causes complaints of fever, chills, malaise, sore throat, and painful neck mass. There is redness in the throat, the membrane on the tonsil and painful swelling in the neck glands. In the later stages of the disease, inflamed discharge can be seen with the opening of the swollen lymph nodes to the skin. Diagnosis is made by blood tests. Blood tests come back positive 16 days after encountering the disease. They are treated with the appropriate group of antibiotics. Food and water should be analyzed as a resource to protect the health of the rest of the community.

Corynebacterium Diphtheriae:

It is a disease that can be given as an example to the diseases that are about to take off in the world with measures such as public health and vaccination. It is very rare since diphtheria toxoid application was made. However, it has the potential to cause epidemics in communities that have been vaccinated but not immunized at a protective level. Transmission occurs through infected secretions in the nose, throat, eyes and skin lesions. The organism that enters through the mouth or nose adheres to the upper respiratory tract mucosa (cover) and multiplies, causing inflammation and damage to tissue vitality through the toxin it secretes. It forms a gray-black sticky, patchy membrane on the tonsils, nose, pharynx, larynx (larynx), trachea, conjunctiva, skin or genital area. This is called a pseudomembrane. This pseudomembrane may be in more than one area. However, the most common place is the throat area.

When this membrane is removed, bleeding underneath is typical for this organism infection. Sore throat and fever occur 1-2 days before this pseudomembrane is formed. Signs and symptoms can range from mild to very severe. It can be life-threatening if the infection spreads to the lower respiratory tract. A “bull’s neck” appearance may occur due to swelling of the lymph nodes in the neck area. This may cause respiratory distress by pressing on the lower larynx area. The toxin of the bacteria spreading through the blood affects other tissues; It can cause myocarditis (heart muscle inflammation), neuritis (nerve inflammation) and acute tubular necrosis (kidney disease). Diagnosis is made by isolating the organism. Antitoxin and antibiotics are used in the treatment. When the diagnosis is made, the patient should be followed closely in terms of supportive treatment. Because these patients may have difficulty in swallowing and obstruction of the upper respiratory tract. It is recommended to repeat diphtheria toxoid every 10 years, especially in those who travel frequently to places where the disease can be seen.

Yersinia Enterocolitica:

It is an organism that often causes intestinal infections. However, it causes pharyngitis in 20-30% of the population it causes intestinal infection. It can cause pharyngitis without intestinal infection. The membrane on the tonsils, painful swelling in the lymph nodes of the neck region, fever and an increase in blood leukocyte levels are observed. This organism cannot cause pharyngitis frequently, but in case of delay in diagnosis, it can cause obstruction in the respiratory tract, spread of bacteria to the blood and other organs, and death. b- Thalesemia (Mediterranean anemia) patients are a high risk group for this organism infection. When this organism is detected, it is treated with the appropriate antibiotic group.

What are the fungi that cause pharyngitis?

Candida species : Causes pseudomembranous candidiasis (thrush) in the mouth-throat area. Candida albicans is a type of fungus that is normally found in the oral cavity without causing disease. However, in cases where the person’s defense system is weakened (in HIV-positive people, etc.), they can multiply and create a disease picture called opportunistic infection. Candida is positive in 73% of people who receive radiation therapy for any cancer in the head and neck region, but it causes infection in only 27%. Dry mouth (radiation to the area, Sjögren’s syndrome, as a side effect of medication), use of steroid-containing air used in asthma and similar conditions, broad-spectrum antibiotics, in cases of immunodeficiency, diabetes, Cushing’s syndrome, end-stage diseases and high carbohydrate diet Risk for thrush are factors. It causes complaints of discomfort in the mouth, burning, changes in the sense of taste and difficulty in swallowing. Apart from the mouth and throat area, it can be seen in the buccal mucosa, hard palate, tongue, larynx, and esophagus. Diagnosis is made by microscopic examination or culture. The disease is usually regional. However, in rare cases, the disease can be life-threatening if it spreads. It is treated with good oral hygiene and antifungal drops. Systemic (oral pills, or intravenous drugs) treatment is given to risk group patients.

Apart from infections, what are the conditions that can cause pharyngitis and sore throat?

abscesses (peritonsillar), parapharyngeal,retropharyngeal),

epiglottitis

Cancers (squamous cell cancer, lymphoma),

Autoimmune diseases (Behçet’s disease, pemphigus, sarcoidosis),

Laryngopharyngeal reflux (throat reflux, overflow of stomach contents)

Postnasal drip

Eagle’s syndrome,

Glossopharyngeal neuralgia,

Crohn’s disease,

foreign body,

Trauma,

some drugs,

Causes such as air pollution are non-infectious conditions that cause sore throat.

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