#17 Sore throat? Absent cough? Ask Doctor Centor.

October 31, 2016 | By Matthew Watto, MD

Dr. Robert Centor’s Knowledge Food, Part 2!  On this episode of The Curbsiders, we continue our discussion with the legendary Dr. Centor, focusing on pharyngitis and the highly entertaining origin of the Centor Criteria.  Not only do we learn how to dominate pharyngitis, but we also uncover one of Dr. Watto’s knowledge deficits – Lemierre’s Syndrome.  (He owes us a two minute talk on Lemierre’s Syndrome in case you’re wondering. I know I am.)

Clinical Pearls:

1. Admit your own limitations!  Many overestimate their skills as a clinical educator.
   1. Preadolescents get streptococcal pharyngitis (…or it’s nothing).
   2. Adolescents are much more complicated with streptococcus, EBV, CMV, acute HIV, fusobacterium, and multiple other causes.
2. Important: Separate the causes of pharyngitis in preadolescents and adolescents.
   1. General rule: Sore throats should not cause rigors; if present then admit patient, obtain blood cultures, and start antibiotics.
3. Do NOT miss a peritonsillar abscess or Lemierre’s Syndrome in acute pharyngitis.
4. Pharyngitis improves within three to five days.  Failure to improve should prompt a more thorough investigation.
5. Lemierre’s Syndrome (1 in 70,000 untreated pharyngitis patients) is septic thrombophlebitis of the internal jugular vein.  The treatment is IV antibiotics and NOT anticoagulation.  
6. Dr. Centor and the IDSA recommends Amoxicillin once daily and, if penicillin allergic, Clindamycin.  The most recent IDSA update recommends a 10-day course of Amoxicillin (50mg/kg up to 1000mg once daily).

Dr. Centor’s “Take-Home” Points:

1. Adolescents tend to have more complicated pharyngitis
2. Pharyngitis and rigors?  Admit, obtain cultures, and start antibiotics.
3. Sore throats don’t get worse and, if they do, you need to rethink the case

Disclosures:
Dr. Centor reports no relevant financial disclosures for this topic.

Learning objectives:
By the end of this podcast listeners will be able to:

1. Identify the limitations of the Centor Criteria in regards to (a) preadolescents and (b) adolescents, taking special precautions in the adolescent population
2. Understand which acute pharyngitis patients require a more thorough investigation
3. Be able to identify Amoxicillin as the treatment of choice for acute bacterial pharyngitis with Clindamycin as the second-line antibiotics choice.

Links from the show:

1. Check our Dr. Centor’s wonderful blog, at http://www.medrants.com or on twitter https://twitter.com/medrants
2. Centor’s Criteria (MDCalc) — http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/
3. IDSA Guidelines on Diagnosis and Management of Group A Streptococcus Pharyngitis – http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html
4. Original article using the Centor score for pharyngitis https://www.ncbi.nlm.nih.gov/pubmed/6763125?dopt=abstract
5. Dr. Centor’s article on fusobacterium Centor RM, et al. The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/M14-1305.