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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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5 . 2  -  General complications

General complications, which are mainly renal, articular, and cardiac, are related to b-hemolytic Streptococcus A.

The pathogenesis, which has been discussed at length, is likely based on immune mechanisms. These complications are thought to be consecutive to the release of immune complexes, associating b-hemolytic Streptococcus A antigens and IgG immunoglobulins, which are deposited mainly in the renal glomeruli and joints, triggering complement activation and inflammatory reactions.

→ Acute glomerulonephritis

Acute glomerulonephritis is often edematous or hematuric, occurring 10 to 20 days after streptococcal angina. While the evolution is generally favorable in children, acute glomerulonephritis can lead to irreversible kidney failure, especially in adults.


→ Acute articular rheumatism and post-streptococcal syndromes

These conditions start 15 to 20 days following the initial tonsil infection:

• either in a brutal and eloquent way by polyarthritis;
• or insidiously in the case of inaugural, moderate myocarditis.
• There is an inverse relationship between the severity of joint damage and the risk of developing cardiac dysfunctions.
• Articular manifestations are more frequently encountered:
• the typical clinical form, now rare, is characterized by migrating, transient, polyarthritis of the large joints. The joint is the site of pain limiting mobility, redness, warmth, and swelling;
• this form is currently replaced either by simple arthralgia, or by a mono-arthritis, which may evoke the diagnosis of purulent arthritis. The spontaneous duration of the rheumatic episode is about 1 month. It disappears without sequelae, while other areas may be affected, with no systematic order.

Cardiac manifestations make up the essential prognostic element :

• their prognosis is both immediate, involving the risk of heart failure, and delayed, involving  the risk of valvular sequelae. They are even more common as the subject's age decreases. Cardiac involvement may be either an isolated impairment or involve all three cardiac layers. Cardiac ultrasound is instrumental in confirming the diagnosis and monitoring disease progression;
• endocardial involvement is the most serious condition. At the beginning, it is detected via a heart murmur related to cardiac insufficiency, which is of mitral rather than aortic origin. At a later stage, murmurs related mitral and aortic stenosis may occur;
• myocardial involvement is reflected by the appearance of heart failure signs, which are of very poor prognosis. Rhythm, repolarization, and conduction disorders are common and evocative. On chest x-ray, the heart's size is increased;
• pericardial involvement, which is very uncommon, is suspected in the presence of precordial pain, pericardial friction rub sounds, increased cardiac size on imaging, or repolarization abnormalities on ECG.

Skin manifestations :

• Meynet nodules are exceptional: subcutaneous, firm, painless, ranging from a few millimeters to 2 cm, these nodules occur next to bone surfaces and tendons, especially near the elbows, knees, wrists, and ankles. They last for 1 to 2 weeks;
• Erythema marginatum has a fleeting evolution, and is characterized by pink macules that are non-pruritic and found on the limb roots and on the trunk.

Neurological manifestations: Sydenham's chorea should be evoked in the presence of involuntary, disordered, anarchic, diffuse, and bilateral movements. Similarly to valvular stenosis, these neurological symptoms occur only following numerous inflammatory relapses.

General manifestations: fever is very common and non-sustainable, responding well to anti-inflammatory drugs, including non-steroidal anti-inflammatory agents. Abdominal pain, linked to mescentric adenolymphitis or cardiac liver, is observed in 5-10% of cases. There is hyperleukocytosis, and inflammatory markers are raised, with sedimentation rate levels exceeding 100 in the first hour.

Curative treatment :

• in major post-streptococcal syndromes: the patient must rest in bed for 3 weeks, under corticosteroid treatment (to limit or prevent cardiac valvular changes, at a dose of 2 mg/kg/day without exceeding 80 mg/day until normalization of the sedimentation rate, followed by gradual reduction) and penicillin V to sterilize the pharyngeal site, which is relayed by subsequent prophylaxis;
• in minor post-streptococcal syndromes: salicylates and penicillin V.

Preventive treatment :

• antibiotic prophylaxis (to prevent any AAR recurrences in relation to GAS pharyngeal infection) is initiated at the end of curative treatment: benzathine penicillin  (Extencilline) and in case of allergy, a macrolide.
• duration of antibiotic prophylaxis is 5 years in cases of major syndromes, but only 1 year for minor forms. It is recommended to re-initiate preventive treatment when the patient must stay in closed community (station, dormitory, etc.).