Focused Throat Exam: Differential Diagnosis Case Study

Patient Information

Lily, a 20-year-old female.

Subjective:

CC (chief complaint):

Sore throat for 3 days.

HPI: 20-year-old college student has a 3-day history of sore throat and pain with swallowing as well as decreased appetite and headache. Lily reports a few similar cases on her campus during the past 2 weeks. Additional symptoms include a runny nose and slight hoarseness in her voice without sound congestion.

Location: throat.

Onset: 3 days ago.

Character: soreness.

Associated signs and symptoms: sore throat, pain with swallowing, decreased appetite, headache, runny nose, slight hoarseness.

ROS:

• General: Decreased appetite.
• EENT: Eyes: No pain in the eyeballs, no photophobia, or lacrimation. Ears, Nose, Throat: Runny nose, sore throat, pain with swallowing, slight hoarseness, no upper airway congestion.
• Skin: no rash or itching.
• Cardiovascular: No chest pain, chest pressure, or chest discomfort. No edema.
• Respiratory: No shortness of breath, cough, or sputum.
• Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
• Neurological: Headache.
• Musculoskeletal: No muscle, back pain, joint pain, or stiffness.
• Hematologic: No anemia, bleeding, or bruising.
• Allergies: No history of asthma, hives, eczema, or rhinitis.

Objective:

Rhinorrhea and slight dysphagia. No perceptible upper airway congestion.

Assessment:

A reported 3-day history of sore throat and pain with swallowing along with decreased appetite and headache. Headache without previous head trauma. Decreased appetite with no reports of nausea or vomiting.

Differential Diagnosis:

• Influenza. Influenza is an acute infectious disease with an aerosol transmission mechanism of the pathogen, characterized by a short incubation period (from 10-12 hours to 7 days), massive spread, fever, symptoms of intoxication and damage to the airways, as well as a high frequency of complications (Fitzner et al., 2018). The clinical picture of influenza can vary significantly depending on the age of patients and the state of their immune system, the serotype of the virus, its virulence, etc (Fitzner et al., 2018). A typical symptom complex of diseases is characterized by fever, manifestations of general infectious intoxication, and a syndrome of damage to the respiratory tract, nervous, and cardiovascular systems. Fever is most cases begins with dizziness. Body temperature reaches its maximum level on the first day (38–40 ° C). The duration of the febrile period is from 2 to 5 days, rarely up to 6-7 days, and then the temperature decreases (Bailey et al., 2018). Simultaneously with an increase in temperature, the patient begins to feel general weakness, lethargy, sweating, muscle pain, severe headache, and dizziness. The likelihood of an influenza diagnosis for Lily can increase in case she shows the symptoms of a fever.
• Human parainfluenza viruses (HPIVs). HPIVs are characterized by a low temperature, mild symptoms of intoxication, and damage to the respiratory tract with the development of laryngitis. The onset is gradual, with the appearance of a cough and a runny nose. The temperature is often sub febrile lasting from 1 to 8 days but may remain normal or be febrile. Such signs as malaise, headache, and aches, in contrast to influenza, are poorly expressed or absent. One of the main symptoms is laryngitis, which is expressed by a sore throat, dry rough cough, and hoarseness up to aphonia (Bailey et al., 2018). A common symptom is a runny nose, usually mild, with difficulty breathing due to swelling of the nasal mucosa. There is hyperemia of the mucous membrane of the oropharynx, but unlike influenza, it is less bright and without a cyanotic shade. Symptoms of tracheitis are rare, with a cough that can last up to 2 weeks. Prolonged bronchitis is associated with the addition of a secondary bacterial flora and is a complication of HPIVs (Bailey et al., 2018). The febrile period is longer than with influenza. The likelihood of an HPIV diagnosis for Lily is high since she has the symptoms of a sore throat, hoarseness, and headache.
• Coronavirus infection. The severity of the course of coronavirus infection depends on the patient’s age. In children under 3 years of age, the disease is characterized by an acute onset with severe intoxication, severe damage to the upper respiratory tract in the form of nasopharyngitis, with a possible spread of the inflammatory process to the larynx and trachea (laryngotracheitis). In 80% of young children, the disease is complicated by the development of laryngitis (Xie et al., 2020). In older children, the disease begins gradually and proceeds with severe rhinitis and slight malaise. Some patients may have a dry cough and the development of laryngitis. Coronavirus infection is sometimes characterized by acute gastroenteritis syndrome without catarrhal symptoms. The duration of the disease is 5-7 days. SARS (atypical pneumonia) is a severe form of coronavirus infection, characterized by a cyclical course, severe intoxication, predominant lesion of the alveolar epithelium, and the development of acute respiratory failure (ARF) (Xie et al., 2020). It is believed that the emergence of the SARS virus was the result of mutations of previously known types of coronavirus. Lily’s symptoms along with close-quarter living on campus increase the risk of coronavirus transmission.
• Enterovirus infection. Enterovirus infection is a large group of anthroponoses with a fecal-oral mechanism of transmission of the pathogen caused by enteroviruses of the Coxsackie group and ECHO, which are characterized by polymorphism of the clinical picture with damage to the central nervous system, muscles, mucous membranes, and skin (Neisi et al, 2019). The clinical signs of enteroviral acute respiratory infections differ depending on the type and serotype of the virus. In case of infection with Coxsackie viruses, the disease is characterized by damage to the upper respiratory tract in the form of rhinopharyngitis against a background of moderate intoxication. If the disease is caused by ECHO viruses, then tracheitis or tracheobronchitis with severe intoxication develops. Lily does not appear to have rhinopharyngitis or tracheitis, which makes enterovirus infection less probable than other throat conditions.
• Rhinovirus infection. It is characterized by a predominant lesion of the nasopharyngeal mucosa and a mild course. From the first hours of illness, the main symptom is rhinitis with profuse serous discharge, which lasts from 7 to 14 days. The mucous membrane is moderately hyperemic and edematous, the scleral vessels are injected, and conjunctival hyperemia. The skin at the entrance to the nose is often macerated. Symptoms of intoxication, as a rule, are absent, the temperature remains normal or rises to subfebrile (Neisi et al, 2019). High fever occurs with the development of complications such as sinusitis, otitis media, and bronchitis. Lily’s symptoms along with similar reported cases increase the risk of rhinovirus infection.
• Adenovirus infection. A distinctive feature of adenovirus infection is a combined lesion of the respiratory tract, conjunctiva of the eyes with a sharp exudative component, and the involvement of lymphoid tissue in the pathological process. In adults, adenovirus infection occurs more often in a latent form or the form of a clinically delineated disease. The disease begins with catarrhal symptoms, and general toxic symptoms are expressed mostly moderately, even with high fever, longer than with influenza (Xie et al., 2020). The exudative nature of the lesion of the respiratory tract is manifested by swelling of the nasal mucosa with severe nasal congestion and profuse serous-mucous discharge. The pathological process always involves the back wall of the pharynx and tonsils. Unlike other acute respiratory viral infections, adenoviral disease is accompanied by lymphadenopathy (Xie et al., 2020). The likelihood of an adenovirus infection diagnosis for Lily is not high since she does not show the symptoms of severe nasal congestion and lymphadenopathy.

Pan: Physical examination of the ENT, temperature assessment, auscultation of lung sounds, and palpation of lymph nodes should be done. A rapid nasal swab, rapid antigen detection test (RADT), a complete blood count, and a mononucleosis spot test should be indicated to detect the pathogen. Treatment of Lily’s symptoms should be based on the testing results. Treatment of patients with mild uncomplicated influenza or other acute respiratory viral infections is carried out at home under the supervision of a physician (Laporte & Naesens, 2017). Persons in constant contact with the patient should wear 4-layer masks both in hospitals and at home, and wash their hands. Lilly should rest and sleep at least 7-8 hours a day (Laporte & Naesens, 2017). She should have a sufficient fluid intake and remember about general hygiene measures, as well as mask regime and social distance. Frequent ventilation of the room can also be helpful to reduce the risk of infection transmission. Wet treatment of premises with disinfectants is recommended. Pathogenetic and symptomatic therapy may include antiviral medications, vitamins, and immunotherapy.

References

Bailey, E. S., Fieldhouse, J. K., Choi, J. Y., & Gray, G. C. (2018). A mini-review of the zoonotic threat potential of influenza viruses, coronaviruses, adenoviruses, and enteroviruses. Frontiers in Public Health, 6, 104.

Fitzner, J., Qasmieh, S., Mounts, A. W., Alexander, B., Besselaar, T., Briand, S.,… & Hauge, S. (2018). Revision of clinical case definitions: Influenza-like illness and severe acute respiratory infection. Bulletin of the World Health Organization, 96(2), 122-128.

Laporte, M., & Naesens, L. (2017). Airway proteases: An emerging drug target for influenza and other respiratory virus infections. Current Opinion in Virology, 24, 16-24.

Neisi, N., Abbasi, S., Makvandi, M., Salmanzadeh, S., Biparva, S., Nahidsamiei, R.,… & Ahmadi Angali, K. (2019). Detection of common respiratory viruses in patients with acute respiratory infections using multiplex real-time RT-PCR. Jundishapur Journal of Microbiology, 12(11).

Xie, C., Lau, E. H., Yoshida, T., Yu, H., Wang, X., Wu, H.,… & Yen, H. L. (2020). Detection of influenza and other respiratory viruses in air sampled from a university campus: A longitudinal study. Clinical Infectious Diseases, 70(5), 850-858.