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Fatigue, Sore Throat, and Cough in a 24-Year-Old Active Duty Man

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Walter Reed Army Medical Center

A 24-year-old active duty male smoker presented with 3 days of fatigue, rhinorrhea, and sore throat. The diagnosis and management of pharyngitis, including a field friendly approach, are reviewed. The impact of the discontinuation of the adenovirus vaccine to military recruits is highlighted. The effects of smoking among military personnel are discussed, and smoking cessation measures are reviewed.

Introduction

A 24-year-old active duty E-3 Caucasian male presented to the General Internal Medicine Clinic at Walter Reed Army Medical Center (WRAMC). Three days previous, the patient noticed rhinorrhea, a sore throat, and a nonproductive cough, but denied shortness of breath, headache, rash, fever, or chills. The symptoms continued for the next 2 days with little improvement. The patient had not tried any over-the-counter cold relief agents or analgesics.
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Young active duty soldiers with nasal congestion, sore throat, and cough are most likely to be suffering from a viral URI. ' This is especially true in new recruits where adenovirus can be responsible for up to 70% of patients with this set of symptoms. The U.S. military previously vaccinated new recruits against adenovirus, until 1999, when Wyeth Lederle stopped producing the vaccine.1 After the discontinuation of immunization, adenovirus has rapidly reemerged as the leading cause of febrile respiratory illnesses among recruits, and further epidemics are anticipated.2 Consequently, physicians will encounter a higher prevalence of adenovirus infections, making the correct diagnosis of streptococcal pharyngitis, and the decision of when to prescribe antibiotics, more challenging. In addition to adenovirus, there are numerous other viruses that can cause URIs, including scores of strains of rhinovirus, although the symptoms tend to be more mild and self-limiting.

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Although viral URI is the most likely diagnosis, it is imperative to consider other potential pathogens. GABHS is an important diagnostic consideration because failure to treat risks the development of sequelae such as acute rheumatic fever. Infectious mononucleosis caused by Epstein-Barr virus warrants consideration in young patients presenting with sore throat, fever, malaise, and cervical adenopathy on physical examination, particularly if symptoms are persistent, or if hepatomegaly, splenomegaly, and/or elevated liver function tests are present.

Sexually transmitted diseases, including gonorrhea, chlamydia, and HIV, should not be overlooked in the differential diagnosis of pharyngitis in soldiers. A sexual history, with particular attention to oral-genital and oral-anal contact, should be taken in all soldiers presenting with pharyngitis. HIV seroconversion illness can mimic mononucleosis. A screening HIV enzyme-linked immunosorbent assay should be performed if HIV is suspected. If it is negative and suspicion is high, an HIV RNA polymerase chain reaction (viral load) should be performed.

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The patient was afebrile and had stable vital signs. Physical examination revealed mild pharyngeal erythema without exudates. He had no palpable lymphadenopathy, rash, hepatomegaly, or splenomegaly.

Streptococcal pharyngitis typically presents with sudden onset of sore throat, pain on swallowing, and fever. The Centor Criteria (Table I) are useful in the process of deciding when a patient with pharyngitis should be treated with antibiotics.3 The criteria include tonsilar exudates, fever by history or at time of visit, tender anterior cervical adenopathy, and absence of cough. The presence of three or four of these criteria has a positive predictive value of only 40 to 60%. The lack of three or four criteria may be more useful and has a negative predictive value of 80%.3 Unfortunately, clinical criteria alone are often unreliable in establishing a diagnosis of streptococcal pharyngitis.

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Over the past few years, debate has surfaced over how to best use the Center Criteria in directing therapy. Snow et al.4 have proposed a decision tree based on the Centor Criteria that has been accepted by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) as a guideline for treating potential GABHS pharyngitis.5 They recommended two different treatment algorithms. The first recommends testing everyone who meets two or three Centor criteria using a RADT, and then treating patients with positive tests or those who meet all four criteria with antibiotics. The second method is based solely on clinical criteria and treats all patients who meet three or four Centor criteria. The ACP-ASIM only advises using throat cultures when RADT sensitivity at your laboratory is less than 80% (sensitivity ranges from 70 to 90%, depending on population studied), during outbreaks, if tracking antibiotic resistance, or when gonococcus is a potential diagnosis.4-6

The Infectious Disease Society of America (IDSA) believes that this method overtreats patients who may have nonstreptococcal pharyngitis.7 They recommend that all adults suspected of having acute GABHS pharyngitis have the diagnosis confirmed by RADT before antibiotic treatment, unless the diagnosis can be excluded on clinical (Centor Criteria) or epidemiological grounds. The IDSA recommends using a throat culture or an RADT to confirm the diagnosis before treating with antibiotics. There is no need to confirm a negative RADT with culture in adults; however, the IDSA does recommend throat cultures in children and adolescents when the RADT is negative, given the higher prevalence in this age group.7

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(c)  Remedy Your Sore Throat 2006 - Author List - Sitemap
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