At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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What is the Best Antibiotic for Strep Throat?

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69

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Did a Case of Lemierre's Syndrome Influence Super Bowl XLVII?

Image by Keith Allison from Wikipedia

Lemierre's syndrome is an exceedingly rare complication of tonsillitis characterized by an infected clot of the jugular vein leading to sepsis. It may also have potentially influenced Super Bowl XLVII due to an interesting quirk in history.

Back in 2008, a former Heisman Trophy winner from Ohio State University named Troy Smith was the quarterback for the Baltimore Ravens. Great things were expected of him as he was gearing up to start in the third preseason game of the 2008 season.

Unfortunately... you guessed it... he came down with Lemierre's Syndrome.

Which allowed for a rookie quarterback named Joe Flacco to step in.

Joe Flacco went on to lead the Baltimore Ravens to a Super Bowl win in 2012.

Troy Smith, in the meantime, has never quite recovered professionally since his bout of Lemierre's Syndrome.


Sources:
Troy Smith. Wikipedia

Joe Flacco. Wikipedia

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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Periodic Fevers in a Child - PFAPA

Fever in a child is not uncommon. After all, they get a lot of infections whether it be ear infections, tonsillitis, viral syndromes, etc.

However, what can be particularly vexing and confusing for both physicians and families is a child who keeps getting recurring fevers every few weeks out of nowhere for seemingly no reason and no obvious infectious source.

The typical scenario is a child with abrupt onset of fevers to ~102 degrees F or higher that lasts 3-7 days and just as inexplicably disappears... only to come back again 3-6 weeks later. This cycle may be repeated numerous times. In between these fever episodes, the child is completely fine.

This fever cycle may be associated with one or more of the following:

• Aphthous stomatitis (inflammation of the mouth mucosa)
• Pharyngitis (inflammation of the throat mucosa)
• Cervical Adenopathy (large lymph nodes in the neck)

Though a specific finding of aphthous stomatitis or pharyngitis may not be made (child may be uncooperative with a full oral exam), the child will usually complain of a sore throat, swallowing difficulties, or may suffer from poor appetite.

Numerous tests can be obtained during a fever episode without any positive findings. Strep cultures are negative. Bloodwork is unrevealing.

Trial courses of antibiotics make no difference.

What can this be???

It is most likely due to a syndrome called PFAPA (Periodic Fevers, Aphthous stomatitis, Pharyngitis, cervical Adenitis). The hallmark feature of this syndrome is the cyclical almost clockwork regularity of acute-onset high fevers.

What is the treatment?

Tonsillectomy and adenoidectomy (T&A) is almost always curative.

Why?

Given we have no idea what even really causes this syndrome, we also don't really know why T&A works either,  but just know from studies (see references below) that it does work.

Reference:
Long-term Surgical Outcomes of Adenotonsillectomy for PFAPA Syndrome. Arch Otolaryngol Head Neck Surg. 2012;138(10):902-906. doi:10.1001/2013.jamaoto.313

Effectiveness of adenotonsillectomy in PFAPA syndrome: a randomized study. Journal of Pediatrics 2009 Aug; 155 (2) : 250-3.

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Deaths Associated with Codeine Usage in Young Kids

For decades, surgeons have provided young children with prescriptions for pain control after tonsillectomy and/or adenoidectomy surgery, most commonly tylenol with codeine (otherwise known as tylenol #3). Millions upon millions of such prescriptions have been filled and taken without any problems, but there is now a growing concern that such narcotics may be causing more harm than good in a small percentage of kids and perhaps an even greater percentage where it absolutely does nothing. Furthermore, it has now become the subject of an FDA investigation.

Why the sudden concern?

There has been a small but increasing number of children who have suffered anoxic brain damage and even fatalities due to respiratory suppression associated with codeine use. This association was not figured out until recently as such unfortunate incidences were initially felt to be due to medication overdosage, poor care, and/or surgical error.

But now, it is felt that such adverse events were probably due to the administration of codeine itself.

What's going on?

All of the children who died following codeine administration had extra copies of the liver enzyme CYP2D6 which metabolizes codeine to its more potent form morphine [study]. Referred to as ultra-rapid metabolizers, these children metabolize codeine so rapidly to morphine that it leads to respiratory depression or arrest. Substituting codeine for hydrocodone, oxycodone, or other opioids is also unsafe as such narcotics are also metabolized by CYP2D6 and cause even more problems because the CYP2D6 metabolites of hydrocodone and oxycodone are even more potent than morphine. (Of course, on the flip side, there are patients who have minimal CYP2D6 functionality which leads to minimal if any pain relief with codeine.)

Although rare, there has been an increasing number of case reports describing children who have died after receiving codeine for post-operative pain, particularly after tonsillectomy. The most recent report published in 2012 documented the cases of three children who died after receiving standard treatment with tylenol with codeine after tonsillectomy between 2010 and 2011. However, these are only the known documented cases.

Given how rare, changing prescribing patterns may not be warranted... BUT...

What about the possibility that there may be numerous other cases which are not documented or close-calls? As we all know, for every documented case, there's probably numerous other undocumented cases.

To investigate this possibility, a close proxy would be to look at malpractice lawsuits after tonsillectomy. This report did just that looking closely at lawsuits stemming from tonsillectomy complications between 1984 and 2010 and found that the incidence of codeine-related deaths was much higher than the researchers expected. They found that 18 percent of death claims and 5 percent of injury claims resulted from the use of opioids, largely codeine. Indeed, after bleeding, opioid usage was the second most common cause of death in patients after tonsillectomy.

Additionally, death and anoxic brain injury claims associated with narcotic usage were associated with the greatest indemnity with a median payment of more than $900,000 per case.

Though likely impossible to do retrospectively, it would have been interesting to see whether all these children in these lawsuits had multiple CYP2D6 copies or not.

Alternatives to Narcotics

First, there is the question whether tylenol with codeine even helps with pain. Apparently not according to one study. In fact, children who took tylenol alone resumed a normal diet more quickly than kids who received codeine.

In fact, tylenol with codeine is associated with adverse side effects (nausea, dizziness, vomiting, etc) in up to 79% of children who take it [link].

Ibuprofen may also be given for pain control. Though ibuprofen theoretically can increase risk of bleeding due to its anti-platelet activity, numerous studies have not found this to be true.

Given codeine helps minimally with pain and tylenol alone seems to provide adequate pain control, why even given narcotics, especially given the small but significant risk of death associated with this drug?

Pain Control Protocol

Based on all these findings, we feel that narcotics for pain control after tonsillectomy for kids under 7 years of age is not recommended.

Rather, the following protocol is what we will now be implementing:

Tylenol and Ibuprofen over-the-counter as needed to help with pain control. The dosing is weight-based and exact dosing for a given child can be found on the bottle. These medications can be given alternating between Tylenol and ibuprofen every 3-4 hours (Tylenol first, followed by ibuprofen 3-4 hours later, followed by Tylenol 3-4 hours after that, etc). A prescription for a single dose of steroids is also provided which is meant as a one-time dose that can be given anytime 3 days after surgery if the child suddenly seems to have significantly more pain that is not controlled with Tylenol and ibuprofen. Pain in this scenario is often due to inflamed tissues that can be quickly minimized with steroids.

Source:
FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. FDA 8/15/12

Post-Operative Pain in Children Undergoing Tonsillectomy. ENT Today. Sept 2012.

FDA Investigates Codeine Safety After Children’s Deaths. ABC News. 8/15/12

References:
More codeine fatalities after tonsillectomy in North American children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9.

Preventing opioid-related deaths in children undergoing surgery. Pain Med. 2012 Jul;13(7):982-3; author reply 984. doi: 10.1111/j.1526-4637.2012.01419.x. Epub 2012 Jun 13.

Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope. 2012 Jan;122(1):71-4. doi: 10.1002/lary.22438. Epub 2011 Nov 10.

Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope. 2000 Nov;110(11):1824-7.

Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591.

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Tonsillectomy Circa 1940s [video]

I encountered this interesting video of tonsillectomy being performed in a child with sedation (but NO intubation) performed circa 1940s.


Of course, nowadays, tonsillectomy is performed under general anesthesia with intubation for airway protection. Here's a video of the way it is now done.

That is, unless, you practice in other parts of the world where modern medicine is not up to United States standards. In those nations, tonsillectomy is STILL being performed WITHOUT general anesthesia or any sedation for that matter. In fact, here's a blog I wrote earlier this year showing a graphic video depicting tonsillectomy being recently performed in a young child WITHOUT any sedation.

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