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Angina
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Etiology
Angina and acute tonsillitis are acute inflammations of the palatine tonsils.
They occur readily in children and young adults (rarely in babies under 18 months of age), but may also be observed in adults at any age.
Depending on the patient's age, 50 to 90% of angina cases are of viral origin (adenovirus, Influenza virus, respiratory syncytial virus, and para-influenza virus, etc.).
Among the bacterial agents responsible for angina, Group A b-hemolytic streptococcus is often the first to be found (20% throughout the age groups). Angina caused by Group A b-hemolytic streptococcus only represents between 25 to 40% of angina cases in children and 10-25% in adults. It occurs primarily from the age of 3 years onwards, with an incidence peak in children aged between 5 and 15 years. The condition is rare in adults.
Group A b-hemolytic streptococcus angina usually improves within 3 to 4 days, even in the absence of treatment. However, these infections can give rise to potentially serious complications (post-streptococcal syndromes such as acute articular rheumatism [AAR], acute glomerulonephritis [AGN], and local or general septic complications), for which prevention justifies the use of antibiotic therapy.
Due to the inherent risk of Group A b-hemolytic streptococcus infection, and because antibiotics are useless in viral angina cases, only patients suffering from Group A b-hemolytic streptococcal angina can justifiably receive antibiotic treatment (except for highly occasional Corynebacterium diphteriae, Neisseria gonorrhoeae, and anaerobic bacterial infections, which have a different clinical picture).
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Clinical diagnosis
Angina is an inflammation caused by infection of the tonsils, or the entire pharynx. It is a syndrome that combines :
- fever;
- painful discomfort when swallowing (odynophagia);
- changes in the appearance of the oropharynx.
At times, other symptoms may be observed: abdominal pain, rash, and respiratory symptoms (runny nose, coughing, hoarseness, and breathing difficulties). These symptoms are variously associated and variable depending on the causative agent and age of the patient.
Clinical examination of the oropharynx confirms the diagnosis of angina; there are several possible aspects :
- in the vast majority of cases, the tonsils and pharynx are congested: erythematous angina;
- the conditon can be combined with an abundant purulent coating that covers the surface of the tonsils: erythemato-pultaceous angina;
- the pharynx may present vesicles: vesicular angina;
- ulcerative angina and pseudomembranous angina are rarer and should evoke a specific etiology: Vincent's disease, infectious mononucleosis, or diphtheria;
- concomitant sensitive lymph nodes are often present.
However, the aspect of the oropharynx is not predictive of Group A b-hemolytic streptococcal angina. This latter can indeed be erythematous, erythemato-pultaceous, or even unilateral and erosive. Clinical symptoms may facilitate the diagnosis of Group A b-hemolytic Streptococcus (GAS) angina, but their predictive value is often insufficient (Table 1) :
Equally, clinical scores have been proposed, taking into account four items :
- fever >38°C;
- presence of exudate;
- painful cervical adenopathies;
- no coughing.
Each item is worth 1 point, resulting in a score of 0 - 4. Accordingly, a score of 1 indicates a 5% probability of GAS infection. Such a score, notably in adults, enables the decision not to prescribe antibiotics. However, the predictive value of the score is often insufficient.
Generally, due to the inherent risks of GAS infection, the identification of these forms of angina impacts the therapeutic approach chosen.
In cases of erythematous or erythemato-pultaceous angina, as no clinical sign or score exhibits a positive or negative predictive value in confirming the streptococcal origin of the angina (except for typical cases of scarlet fever), only microbiological confirmation tests enable the practitioner to identify patients with GAS angina.
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