Blog | Tuesday, March 24, 2015

The story behind the new sore throat article


Today, our latest sore throat article appears in the Annals of Internal Medicine. The story behind the article starts with this blog!

This post documents the story as of 2009 when I wrote about Expanding the Pharyngitis Paradigm

To recap, I first posted an article about the Lemierre Syndrome in 2002. Because of my long standing interest in adult sore throats, I immediately wondered if the rise in the Lemierre Syndrome should influence pharyngitis management.

Since my thought experiment publication in 2009, working with some great colleagues, we developed a polymerase chain reaction (PCR) for Fusobacterium necrophorum. We did some pilot work and proved to ourselves that the European data that showed a very low rate of F. necrophorum in preadolescents were consistent in the U.S.

Therefore we partnered with the wonderful staff at our college health clinic to prospectively collect throat swabs and clinical data. The European data did not include clinical information, but did suggest that in the 15-30 age group, F. necrophorum pharyngitis occurs at least as often as strep pharyngitis.

We found a wonderful collaborator at Michigan State University who did the PCR testing for group A and group C/G strep. Thus, we had the most complete data on the incidence of 3 bacteria (we also tested for Mycoplasma pneumoniae, but found it very uncommon in our patients) and their clinical presentations.

We hypothesized that F. pharyngitis would resemble strep pharyngitis. We based this hypothesis on our understanding of the Centor score. The score likely works because it captures 3 clues to bacterial pharyngitis (as opposed to viral pharyngitis). Bacterial infections more commonly induce an inflammatory response (exudates and adenopathy), cause fever, and do not cause upper respiratory viral symptoms (lack of cough). Logically we thought that these predictors were non-specific to any bacterial infection.

Our paper supports this hypothesis. The results explain why patients with scores of 3 or 4 do not have strep. Likely many of these patients have a different bacteria, group C/G strep or F. necrophorum. Perhaps there are other bacteria causing the pharyngitis in many of these patients.

We hope that this paper makes us all think about our approach to adolescent and young adult pharyngitis. More on that later.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.