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CASE 19
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A 45-year-old man presents to the clinic with a cough productive of purulent
sputum of 3 weeks’ duration. He says that he had just gotten over a cold a
few weeks prior to this episode. He occasionally has fevers, and he coughs so
much that he has chest pain. He reports having a mild sore throat and nasal
congestion. He has no history of asthma or any chronic lung diseases. He denies
nausea, vomiting, diarrhea, and any recent travel. He denies any smoking history.
On examination, his temperature is 98.6 °F (37.0 °C), pulse is 96 beats/min,
blood pressure is 124/82 mm Hg, respiratory rate is 18 breaths/min, and oxygen
saturation is 99% on room air. Head, ears, eyes, nose, and throat (HEENT)
examination reveals no erythema of the posterior oropharynx, tonsillar
exudates, uvular deviations, or significant tonsillar swelling. Neck examination
is negative. The chest examination yields occasional wheezes, but normal air
movement is noted.
▶ What is the most likely diagnosis?
▶ What is your next step?
▶ What are some common noninfectious causes of cough?
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ANSWERS TO CASE 19:
Upper Respiratory and Ear Infections
Summary: A 45-year-old man presents with
No history of lung disease or smoking
3 weeks of productive cough following an upper respiratory infection
History of occasional fever and coughing so much that he has chest pain
Normal HEENT examination
Occasional wheezes but normal air movement on chest examination
Most likely diagnosis: Acute bronchitis.
Next step: Bronchodilators, analgesics, and antitussives. Antibiotics have not been
consistently shown to be beneficial. The illness is usually self-limited.
Common noninfectious causes of cough: Asthma, chronic obstructive pulmonary
disease (COPD), malignancy, postnasal drip, gastroesophageal reflux disease
(GERD), medication side effect (eg, angiotensin-converting enzyme inhibitors),
congestive heart failure.
ANALYSIS
Objectives
1. Develop a differential diagnosis of cough persisting for 3 weeks or more.
(EPA 1, 2)
2. Understand that most upper respiratory infections are self-limited illnesses.
(EPA 2)
3. Develop an approach for rational prescription of antibiotics for respiratory
infections. (EPA 4)
Considerations
The patient described in the case is a 45-year-old man with no prior history of lung
disease, immunocompromised state, or tobacco use. These risk factors are important considerations since respiratory complaints in the setting of COPD, HIV, or
a smoking history require a higher index of suspicion of lower respiratory tract
infections such as pneumonia. As with any respiratory complaint, the ABCs (airway, breathing, circulation) should be considered. In the ambulatory setting, a very
quick assessment of the patient’s distress level, respiratory use or nonuse of accessory muscles, anxiety level, stridor, and ability to speak sentences helps to distinguish acute emergency situations from conditions that allow for a more relaxed
assessment. The individual described is afebrile, has a normal respiratory rate, and
appears to be comfortable. The lung examination reveals some slight wheezes but
otherwise normal breath sounds and air movement. The most likely diagnosis in
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this setting is acute bronchitis. Chest radiography is not necessarily indicated; however, since the complaint has persisted for 3 weeks, any other abnormal finding such
as dullness on percussion of the chest, history of fever, or clinical suspicion would
be sufficient reason for chest x-ray. Most acute bronchitis is caused by viruses, and
antibiotic therapy is not helpful. It is important to remember that acute bronchitis
is a diagnosis of exclusion. By definition, a diagnosis of acute bronchitis should
not be made in the presence of clinical or radiographic evidence of pneumonia and
should only be made after ruling out other etiologies such as GERD, asthma, and
the common cold. The patient with true acute bronchitis is best treated with bronchodilator therapy such as albuterol and antitussive agents and follow up in 2 to 3
weeks.
APPROACH TO:
Upper Respiratory and Ear Infections
DEFINITIONS
ACUTE BRONCHITIS: Inflammation of the tracheobronchial tree.
PNEUMONIA: Inflammation or infection of the lower respiratory tract involving
the distal bronchioles and alveoli.
CLINICAL APPROACH TO ACUTE BRONCHITIS
Pathophysiology
Acute bronchitis refers to inflammation of the tracheobronchial tree. The inflammatory response to the trigger, whether infectious, allergic, or irritant, leads to
increased mucus production and airway hyperresponsiveness. As bronchitis most
commonly occurs in the setting of an upper respiratory illness, it is seen more
frequently in the winter. Influenza, parainfluenza, adenovirus, rhinovirus, other
viruses, Mycoplasma pneumoniae, and Chlamydia pneumoniae have been implicated
as causes.
Clinical Presentation
As the primary symptoms are nonspecific, other etiologies can be mistakenly
diagnosed as acute bronchitis. In one study, one-third of patients who had been
determined to have recurrent bouts of acute bronchitis were eventually identified
as having asthma. Occupational history may be important in determining whether
irritants play a role.
There are no specific diagnostic criteria for acute bronchitis, although productive cough with purulent sputum is the most common presentation. Other symptoms are often present, including fever, malaise, rhinorrhea or nasal congestion,
sore throat, wheezing, dyspnea, chest pain, myalgias, or arthralgias. The sputum
produced can be of variable color and consistency; the color of sputum is not diag-
nostic of the presence of a bacterial infection.
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The physical examination in bronchitis is typically nonspecific and frequently
is normal. The presence of fever, tachypnea, tachycardia, and blood pressure
abnormalities should be noted. In persons with underlying pulmonary or cardiac
conditions or in persons with more severe symptoms, oxygen saturation by pulse
oximetry may be warranted. Examination of the lungs may reveal rales, rhonchi, or
wheezes, but in most cases it is unremarkable.
Bronchitis is nearly always self-limited in an otherwise healthy individual.
Although most acute bronchitis lasts for less than 2 weeks, in some cases the cough
can last for 2 months or more. Severe cases occasionally produce deterioration in
patients with significant comorbid conditions.
Alternate Diagnoses. Occasionally, findings on examination may suggest a particular etiology or an alternate diagnosis. Prolonged fever, tachycardia, tachypnea,
hypotension, and signs of consolidation on pulmonary examination may suggest a
diagnosis of pneumonia. Pneumonia may present atypically in the elderly and in
persons with chronic lung disease. Clinicians must have a higher index of suspicion
in these populations. When pneumonia is suspected, a chest radiograph should be
obtained to confirm the diagnosis. Conjunctivitis and adenopathy suggest adenoviral infection, although these findings are not specific.
Laboratory Analysis. There is no requirement for obtaining viral cultures, serologic testing, or sputum analyses in a suspected case of acute bronchitis since the
organism responsible is rarely identified and, more importantly, since these tests
have no effect on the subsequent management.
Treatment
The use of antibiotics has not been shown consistently to alter the natural history
of acute bronchitis, except in the case of infection with Bordetella pertussis. While
frequently prescribed for the diagnosis of bronchitis, studies have shown that
antibiotics reduce symptoms by approximately 12 hours. Patients with abnormal
vital signs (pulse ≥ 100 beats/min, respirations ≥ 24 breaths/min, temperature
≥ 100.4°F [38.0°C]), and examination findings consistent with pulmonary consolidation should be evaluated further for the diagnosis of pneumonia and treated
appropriately, if confirmed.
As some of the symptoms of bronchitis are caused by airway hyperreactivity,
bronchodilator therapy has been shown in some studies to offer benefit in reducing
symptoms. Antitussives, such as dextromethorphan and codeine, may have modest
benefits in reducing the cough associated with this illness. Mucokinetic agents have
not been shown to be beneficial and are therefore not recommended.
CLINICAL APPROACH TO OTHER UPPER
RESPIRATORY INFECTIONS
The most common cause of chronic cough in healthy nonsmokers with a normal chest x-ray is the encompassing diagnosis of upper airway cough syndrome
(UACS). This diagnosis encompasses a variety of upper respiratory conditions,
which are distinguished from one another by physical examination findings, signs
and symptoms, and sometimes after a trial of therapy. Some conditions under this
umbrella diagnosis are allergic rhinitis and bacterial sinusitis.
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Rhinosinusitis
Pathophysiology. Rhinosinusitis is the inflammation/infection of the nasal mucosa
and of one or more paranasal sinuses. Sinusitis occurs with obstruction of the
normal drainage mechanism. It is traditionally subdivided into acute (symptoms
lasting < 4 weeks), subacute (symptoms lasting 4-12 weeks), chronic (symptoms
lasting > 12 weeks), recurrent acute rhinosinusitis (four or more episodes of acute
rhinosinusitis per year, with interim resolution of symptoms), and acute exacerbation of chronic sinusitis.
Streptococcus pneumoniae and Haemophilus influenzae are the organisms most
commonly responsible for acute bacterial sinusitis in adults; S. pneumoniae,
H. influenzae, and Moraxella catarrhalis are most common in children. In chronic
sinusitis, the infecting organisms are variable, with a higher incidence of anaerobic
organisms seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species).
Clinical Presentation. The signs and symptoms of rhinosinusitis are nonspecific
and similar to other general upper respiratory tract infection symptoms. As most
viral upper respiratory tract infections improve in 7 to 10 days, expert opinion suggests considering a diagnosis of bacterial rhinosinusitis after 7 days of symptoms
in adults and 10 days in children. The diagnosis is suggested by the presence of
purulent nasal discharge, maxillary tooth or facial pain, unilateral maxillary sinus
tenderness, and worsening of symptoms after initial improvement.
Treatment. Treatment of acute sinusitis should be directed at the likely causative
agents. Amoxicillin and trimethoprim-sulfamethoxazole are widely used first-line
agents, typically for 10- to 14-day regimens. Second-line antibiotics are used for
those who fail to improve on the initial regimen or who have recurrent or severe
disease; these antibiotics include amoxicillin-clavulanic acid; second- or thirdgeneration cephalosporins (cefuroxime, cefaclor, cefprozil, and others); fluoroquinolones; or second-generation macrolides (azithromycin, clarithromycin).
Adjunctive therapy with oral or topical decongestants may provide symptomatic
relief. Topical decongestants should not be used for more than 3 days to avoid the
risk of rebound vasodilation with resultant worsening of symptoms. Nonsteroidal
anti-inflammatory drugs and acetaminophen may provide symptomatic relief of
pain and fever.
Pharyngitis
Pathophysiology. Pharyngitis is an inflammation or irritation of the pharynx and/or
tonsils. In adults, the vast majority of pharyngitis is viral. It can also be bacterial or
allergic in origin; trauma, toxins, and malignancy are rare causes. Since most cases
of pharyngitis in adults are benign and self-limited, a focus of the examination of
a patient with symptoms of pharyngitis should be to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A betahemolytic Streptococcus (GAS) infection.
Pharyngitis occurs with much greater frequency in the pediatric population,
with a peak incidence between 4 and 7 years of age. M. pneumoniae, C. pneumoniae,
and Arcanobacterium haemolyticus are common causes of pharyngitis in teens and
young adults. GAS causes 15% of all adult pharyngitis and approximately 30% of
pediatric cases.
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Clinical Presentation. The cause of pharyngitis cannot always be distinguished
based on history or examination. Sore throat associated with cough and rhinorrhea is more likely to be viral in origin. The presence of tonsillar exudates does not
distinguish bacterial from viral causes because GAS, Epstein-Barr virus (infectious
mononucleosis), mycoplasma, Chlamydia, and adenoviruses, among others, can all
cause exudates.
Infectious mononucleosis, caused by infection with Epstein-Barr virus, is
extremely difficult to distinguish clinically from GAS infection. Exudative pharyn-
gitis is prominent. Features suggestive of mononucleosis include retrocervical or
generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be
seen on peripheral blood smear. The associated splenomegaly can be significant,
as it predisposes to splenic rupture in response to trauma (even minor trauma).
A patient with splenomegaly from mononucleosis should be restricted from
activities, such as sports participation, in which abdominal trauma may occur.
On examination, the patency of the airway must be addressed first. The pres-
ence of stridor, drooling, and a toxic appearance suggest epiglottitis. Patients with
epiglottitis are sometimes seen leaning forward on their outstretched arms, the
so-called tripod position. Patients with suspected epiglottitis need to be managed
in a setting where the airway can be emergently secured, via intubation or cricothyroidotomy. Epiglottitis is a rare infection and is becoming even rarer, with nearuniversal immunization for H. influenzae, type B.
Swelling of the peritonsillar region, with the associated tonsil pushed toward
the midline and with contralateral deviation of the uvula, is consistent with a peri-
tonsillar abscess. This can be seen either as the initial complaint of sore throat,
frequently with associated trismus (pain with chewing), or as a complication of
streptococcal pharyngitis. Suspicion of peritonsillar abscess should prompt immediate referral for surgical drainage of the abscess.
Findings frequently associated with GAS infections include an abrupt onset of sore
throat and fever, tonsillar and/or palatal petechiae, tender cervical adenopathy, and
the absence of cough. GAS can also cause an erythematous, sandpaper-like (scar-
latiniform) rash. The diagnosis of GAS infection can be made by rapid antigen
testing or throat culture. Rapid antigen tests can be conducted in a few minutes
in the office or emergency department setting. They are highly specific but have a
lower sensitivity than throat culture. A positive rapid antigen test would prompt
antibiotic treatment; a negative test should be followed by a throat culture. Throat
cultures are considered the gold standard for diagnosis of GAS infections, although
the sensitivity and specificity of rapid antigen detection testing have improved significantly. Cultures can take 24 to 48 hours, but this is acceptable in most instances,
as the risk of complication from GAS infections is low if treatment is instituted
within 10 days of onset of symptoms.
Treatment. Several clinical guidelines have been proposed to aid in the rapid
diagnosis and management of patients presenting with pharyngitis. One of the
most widely used is the Modified Centor Criteria. In this guideline, a patient is
given a point for each of the following criteria: absence of cough; enlarged/tender
anterior cervical adenopathy; fever of 100.4 °F or higher; and tonsillar swelling/
exudates. One point is also awarded if the patient is age 3 to 14, and one point is
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Table 19–1 • CLINICAL DECISION RULE BASED ON CENTOR SCORE
0-1 No further testing and no antibiotic indicated
2-3 Perform rapid strep or throat culture and treat with antibiotic if positive
4 or more Consider empiric antibiotic treatment
deducted for the age of 45 years or higher. Based on the number of points assessed,
the following decision guidelines are proposed (see Table 19-1).
Penicillin is the antibiotic of choice for GAS pharyngitis. Oral therapy requires a
10-day course of penicillin V. Intramuscular (IM) therapy with 1.2 million units of
penicillin G benzathine is used for adults and children weighing more than 27 kg.
Children who weigh less than 27 kg can receive 600,000 units of penicillin IM. In
penicillin-allergic patients, treatment options include cephalosporins and macrolides.
Complications. Complications from untreated GAS infections are rare but
include rheumatic fever, glomerulonephritis, toxic shock syndrome, peritonsillar abscess, meningitis, and bacteremia. Rheumatic fever, which may complicate
up to 1 in 400 untreated cases of GAS pharyngitis, can cause permanent cardiac
and neurologic sequelae. Glomerulonephritis results from antigen/antibody complex deposition in the glomeruli. Poststreptococcal glomerulonephritis may occur
whether or not the patient receives appropriate antibiotic treatment.
CLINICAL APPROACH TO INFECTIONS OF THE EAR
Otitis Externa
Pathophysiology. Otitis externa (OE) is an infection of the external auditory canal.
The tympanic membrane may be uninvolved. The most common pathogens include
staphylococci, streptococci, and other skin flora. Some cases have been associated
with the use of swimming pools or hot tubs. This infection (swimmer’s ear) is usually caused by Pseudomonas aeruginosa.
Clinical Presentation. Patients with OE complain of ear pain and, sometimes,
itching. The pain from OE can be severe. Examination shows an inflamed, swollen,
external ear canal, often with exudates and discharge. Movement of the external ear
is usually quite painful.
Treatment. Irrigation and administration of topical antibiotics, frequently combined with a steroid, are usually successful. Patients with diabetes mellitus are at risk
for an invasive external otitis (malignant OE) caused by P. aeruginosa. Treatment for
this condition involves surgical debridement of necrotic tissue and 4 to 6 weeks of
intravenous antibiotics if cranial bones are involved.
Otitis Media
Pathophysiology. Otitis media (OM) is an infection of the middle ear seen primarily
among preschool children, but occasionally in adults as well. Infection of the middle
ear space, caused by upper respiratory tract pathogens, is promoted by edematous,
congested Eustachian tubes that obstruct drainage. Viral infection with serous
otitis may predispose to acute bacterial OM. S. pneumoniae, H. influenzae, and
M. catarrhalis are the most common bacterial pathogens.
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Clinical Presentation. Fever, ear pain, diminished hearing, vertigo, and tinnitus
are common presenting symptoms. On examination, the tympanic membrane may
appear red, but the presence of decreased membrane mobility or fluid behind the
tympanic membrane is necessary for the diagnosis.
Treatment. Most cases of acute OM will resolve spontaneously. Indications for
treatment with antibiotics include prolonged, recurrent, or severe symptoms.
Numerous antibiotics can be used for treatment. Amoxicillin remains the recommended initial therapy. Alternative treatments include amoxicillin-clavulanic acid,
trimethoprim-sulfamethoxazole, or second- and third-generation cephalosporins.
Complications are uncommon but include mastoiditis, bacterial meningitis, brain
abscess, and subdural empyema.
CASE CORRELATION
See also Case 2 (Dyspnea [Chronic Obstructive Pulmonary Disease]),
Case 24 (Pneumonia), and Case 56 (Wheezing and Asthma).
COMPREHENSION QUESTIONS
19.1 A 30-year-old woman with no past medical history presents with a produc-
tive cough of 2 weeks’ duration. She states she also has had a runny nose,
body aches, congestion, and fevers for the past week. In the office, she is normotensive, with a normal pulse and a temperature of 101.2 °F. Her physical
examination is significant for sinus tenderness, boggy nasal turbinates, and
crackles in the left lower lobe lung fields. Which of the following is the best
initial step in management?
A. Reassure the patient that she likely has a viral infection, and it will resolve
on its own
B. Order a rapid strep test and treat if positive
C. Prescribe amoxicillin for a likely bacterial infection
D. Order chest x-ray to rule out possible pneumonia
19.2 A 5-year-old boy is brought to the clinic with cough, congestion, runny nose,
and low-grade fever for the past 3 days. He has been treated with acetaminophen for fever and given honey for his cough. He has been eating well and
has been active at home. On examination, his temperature is 99.7 °F, and his
vital signs are otherwise normal. He is active, playful, and smiles during the
encounter. You note that his right tympanic membrane is red and bulging, but
the left tympanic membrane is normal. His examination is otherwise normal.
At this time, the best step in management is which of the following?
A. Prescription for amoxicillin for OM
B. Reassurance with a follow-up visit if not improving in the next 10 days
C. Referral for a hearing test
D. Prescription for ciprofloxacin otic drops for OE
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19.3 A 13-year-old girl presents with fever and sore throat of 48 hours’ duration.
She has a temperature of 101 °F in the office and is tachycardic, with a pulse
of 118 beats/min. Her physical examination is positive for tender, enlarged
left cervical lymphadenopathy and tachycardia. Her pharynx is erythematous
with tonsillar enlargement or exudate. She has had no cough. What is the
best step in management?
A. Treat empirically with antibiotics
B. Order rapid strep test and, if positive, treat with antibiotics
C. Neither further testing nor antibiotics
D. Order throat culture and, if positive, treat with antibiotics
ANSWERS
19.1 D. Acute bronchitis is a diagnosis of exclusion in the absence of clinical
or radiographic findings concerning for pneumonia. In this patient with
fevers, productive cough, and rales on lung examination, it is important to
rule out pneumonia and not merely assume it is a self-limited viral infection
(answerA). If there is a strong clinical suspicion of community-acquired
pneumonia, a chest x-ray is not necessary, and outpatient treatment with
antibiotics can be initiated; however, amoxicillin is not a good choice, as
there is high resistance to this agent (answer C). The diagnosis of streptococcal pharyngitis is made with a rapid strep test or throat culture
(answerB), and the decision to order these in the office is guided by the
Modified Centor Criteria based on the following factors: age, presence of
tonsillar exudates, fever, and absence of cough.
19.2 B. The incidental physical finding of a red tympanic membrane is common in
a child with an upper respiratory infection. This is consistent with an OM,
but at this time it does not require antibiotic treatment (answers A). Most
OM spontaneously resolves. In the absence of prolonged or severe symptoms,
watchful waiting is the most appropriate management at this time. This presentation is not consistent with OE (answer D). Hearing loss (answer C) is
not generally associated with OM.
19.3 A. Management of strep pharyngitis is frequently guided by the Modified
Centor Criteria, which calculate a probability of strep throat based on a scoring system. This patient gets one point each for the presence of fever, tender
cervical adenopathy, erythematous pharynx and tonsillar exudate, absence
of cough, and age, which is a score of 5. You could reasonably consider an
empiric antibiotic treatment for GAS since the likelihood of streptococcal
pharyngitis would be about 50%. Thus, the other answer choices (answer B,
rapid strep test and antibiotics; answer C, no further testing or antibiotics;
and answerD, throat culture and antibiotics) would not be as applicable with
such a high likelihood of GAS.
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