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• Prerequisites and learning objectives
• Lesson
  • Content
    • 1 - Pathophysiology - General information
    • 2 - Rhinopharyngitis
      • 2.1 - Etiologies
      • 2.2 - Diagnosis
      • 2.3 - Treatment
      • 2.4 - Complications associated with rhinopharyngitis
      • 2.5 - Differential diagnosis
      • 2.6 - Hypertrophy of adenoid vegetations causing recurrent rhinopharyngitis
      • 2.7 - Other factors favoring nasopharyngeal infections
    • 3 - Angina
      • 3.1 - Etiology
      • 3.2 - Clinical diagnosis
      • 3.3 - Bacteriological diagnosis
      • 3.4 - Clinical forms
        • 3 . 4 . 1 - Acute catarrhal angina (or erythematous angina)
        • 3 . 4 . 2 - Angina with purulent exudate (or erythemato-pultaceous angina)
        • 3 . 4 . 3 - Pseudomembranous angina (or false-membrane angina)
        • 3 . 4 . 4 - Ulcerative and necrotic angina
        • 3 . 4 . 5 - Vesicular angina
        • 3 . 4 . 6 - Gangrenous, necrotizing angina
      • 3.5 - Treatment
      • 3.6 - Differential diagnosis of angina
    • 4 - Chronic tonsillitis
      • 4.1 - Chronic tonsillitis in children
      • 4.2 - Chronic tonsillitis in adults
    • 5 - Complications of tonsillar infection
      • 5.1 - Local complications
      • 5.2 - General complications
    • 6 - Tonsillectomy indications
      • 6.1 - Indications
      • 6.2 - Contraindications
  • Key points
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3 . 5  -  Treatment

The prescription of antibiotics in GAS angina has several objectives :

• accelerate the disappearance of symptoms;
• decrease the spread of GAS to the surrounding environment: patients are no longer contagious 24 hours after starting antibiotic treatment. Without treatment, the eradication of GAS is achieved over a longer time period, which can extend to up to 4 months;
• prevent post-streptococcal non-suppurative complications, notably acute articular rheumatism (AAR);
• reduce the risk of local and regional suppuration.

→ When should treatment be initiated?

Initiation of treatment can be immediate or postponed to the 9th day of onset of symptoms, as the antibiotic efficiency relative to AAR prevention is maintained in the latter case. This observation allows time for diagnostic investigations to be performed and antibiotic treatment to be tailored to each situation.

→ Which treatment should be provided?

Penicillin is the standard therapeutic agent for angina, being the only one to have demonstrated direct effectiveness in AAR prevention.

• b-lactams, treatment duration of 10 days :
  • penicillin V (for example, Oracillin);
  • ampicillin, including bacampicillin (for example, Penglobe) and pivampicillin (for example, Proampi);
  • oral first-generation cephalosporins  (cefaclor, cefadroxil, cefalexin, cefatrizine, cefradine, and loracarbef).

• Shortened treatment period (validated by AMM), which is preferred in order to improve compliance :
  • amoxicillin (for example, Clamoxyl): 6 days;
  • cefuroxime-axetil (for example, Zinnat): 4 days;
  • cefpodoxime-proxetil (for example, Orelox): 5 days;
  • cefotiam-hexetil (for example, Texodil): 5 days.

Macrolides are only used as an alternative to b-lactam treatment, notably when the latter is contra-indicated, particularly in cases of hypersensitivity. This restricted prescription is due to the risk of macrolide-resistant streptococci.

• Macrolide treatment duration of 10 days :
  • dirithromycine (for example, Dynabac);
  • erythromycin (for example, Erythrocine);
  • roxithromycine (for example, Rulid);
  • spiramycin (for example, Rovamycine).

• Shortened treatment period (validated by AMM) :
  • azithromycine (for example, Zithromax): 3 days;
  • clarithromycine (for example, Zeclar): 5 days;
  • josamycine (for example, Josacine): 5 days.

The combination of amoxicillin-clavulanic acid (for example, Augmentin) and cefixime (for example, Oroken) is no longer indicated for angina.

It is recommended to inform the patient of the following :

• treatment with antibiotics should be limited to GAS-induced angina (except for rare diphteric, gonococcal, and anaerobic germ angina);
• need to respect posology (dose and number of administrations per day) and length of treatment.

Symptomatic treatment aimed at relieving discomfort is notably based on antalgic and antipyretic agents. However, due to their associated risks, neither non-steroidal anti-inflammatory agents at anti-inflammatory dose levels nor systemic corticosteroids should be prescribed.

It is not recommended to administer antibiotics to a patient as a preventative measure. The persistence of symptoms after 2 - 3 days should result in reexamination of the patient.

3 . 6  -  Differential diagnosis of angina

Especially at the early stages or during superficial examination, angina may be confounded with the following:

Tonsillar cancer

The absence of common infection signs, patient's age, unilateral affliction, severe induration and bleeding when touched, as well as lymph nodes of a malignant nature lead to a biopsy being taken, which is the key to diagnosis. Tonsillar cancer should be systematically evoked.

Buccopharyngeal symptoms of hemopathy

• As a consequence of neutropenia: pure agranulocytosis, of drug origin, toxic, idiopathic, etc.
• pseudomembranous lesions are disseminated on the whole pharynx region with rapid expansion;
• lesions do not bleed and are not sore. There is no adenopathy;
• complete blood count and myelogram reveal agranulocytosis without alterations of the other bloodlines.
• acute leukosis: tonsillar involvement is associated with hypertrophic gingivitis. Its necrotic evolution and hemorrhagic tendency should lead to a complete blood count and myelogram being carried out in order to ascertain the diagnosis.

Pharyngeal zona

Due to glossopharyngeal nerve involvement, this condition is rare and characterized by its strictly unilateral vesicular rash, which is located on the soft palate, upper third of the arcus palatini, and hard palate, while respecting the tonsil region.

Aphthosis

While aphthosis specifically involves the gingivobuccal mucosa, it can also be found on the soft palate and arcus palatini. It is characterized by one to several crescent or pinhead shaped ulcers that are yellowish in color and very painful. They can be observed in the context of Behçet's disease.

Bullous rashes

These are rare disorders and mainly concern the field of dermatology: pemphigus, dermatitis herpetiformis (Duhring's disease), etc.

Myocardial infarction

The clinical picture may mimic acute angina, because of severe unilateral tonsil pain. There is no general infectious syndrome. Throat examination is normal. The ECG is the key element for the diagnosis.