Pharyngitis natural history, complications and prognosis: Difference between revisions

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Latest revision as of 13:22, 22 December 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2], Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [3]

Overview

The sore throat, fever, and malaise associated with acute pharyngitis are distressing, but with few exceptions, these illnesses are both benign and self-limited. Many bacterial and viral organisms are capable of inducing pharyngitis, either as a single manifestation or as part of a more generalized illness. History and symptoms are essential to diagnosis to identify the treatable causes (e.g., GAS) to prevent complications.

Natural History

Acute pharyngitis is typically described as the triad of sore throat, fever, and pharyngeal inflammation characterized by erythema and edema, although exudates, vesicles, or ulcerations may also be present.
Although pharyngitis may be a primary disorder, sore throat and pharyngeal erythema may also be prominent in systemic disorders, such as acute retroviral syndrome, or part of a more generalized upper respiratory tract infection.
Most cases of acute pharyngitis are due to common viral infections and are benign,self-limited processes.^[1]
The appropriate recognition of patients with more complicated infections that require diagnostic evaluations and treatment is one of the challenges of primary care medicine.^[2] An estimated 1-2% of acute pharyngitis progresses to recurrent or chronic disease.^[3]
Patients with recurrent episodes of pharyngitis and more than one episode of streptococcal pharyngitis at close intervals associated with laboratory evidence of GAS pharyngitis consider that they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.^[4]

Group A Streptococcus

Strep pharyngitis occurs predominantly, though not exclusively, in school-age children.^[1]
Symptoms develop after a short incubation period of 24 to 72 hours.^[5]
Symptoms can vary widely, with some patients experiencing the full effects of the syndrome while others, such as those who have undergone tonsillectomy, may have milder symptoms.^[1]
Untreated, group A beta-hemolytic streptococcus (GABHS) infection lasts 7-10 days. Patients with untreated streptococcal pharyngitis are infectious during the acute phase of the illness and for one additional week.
Effective antibiotic therapy shortens the infectious period to 24 hours, reduces the duration of symptoms by about one day, and prevents most complications.^[5]

Corynebacterium diphtheriae

The incubation period of Corynebacterium diphtheriae infection range between 2-4 weeks.^[5]
Diphtheria common in children and primarily among unimmunized or poorly immunized members of socioeconomically disadvantaged groups.^[1]

Complications

Identifying the cause of pharyngitis, especially GABHS, is important to prevent potential life-threatening complications.☃☃ Serious complications of pharyngitis may include peritonsillar abscess or retropharyngeal abscess.☃☃ Complications of pharyngitis based on the causing agent include the following: ^[6]


Pathogen	Complications
Common complications
Group A Streptococcus	Suppurative complications Tonsillar abscess^[6] Sinusitis Otitis media Necrotizing fasciitis Meningitis Jugular vein thrombophlebitis Non-suppurative complications Acute rheumatic fever (ARF)^[6] Scarlet fever Streptococcal toxic shock syndrome^[6] Acute glomerulonephritis (Post-streptococcal glomerulonephritis)^[5] Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)
Influenza	Pneumonia Encephalitis Aseptic meningitis Guillain-Barre syndrome Transverse myelitis Myositis and rhabdomyolysis
Adenovirus	Laryngotracheitis Bronchitis Pneumonia Otitis media Meningoencephalitis Hepatitis Myocarditis Nephritis Neutropenia Disseminated intravascular coagulation
Cocksackie A virus	Aseptic meningitis Myocarditis Acute flaccid paralysis Conjunctival ulceration Brainstem encephalitis
Epstein barr virus	Airway obstruction Splenic rupture X-linked lymphoproliferative disease Lymphomatoid granulomatosis
Less common complications
Gonococcus	Disseminated gonorrhea Meningitis Endocarditis
Diphtheria	Airway obstruction^[1] Myocarditis Polyneuropathies 10th cranial nerve disorder 9th cranial nerve disorder Peripheral motor neuropathy Diaphragm paralysis Neurogenic bladder dysfunction Acute renal failure Septicemia
Heamophilis influenza	Retropharyngeal abcess Epiglottitis
Fusobacterium necrophorum	Peritonsillar abscess Lemierre's syndrome
Parainfluenza virus	Retropharyngeal abscess Pneumonia

Group A Streptococcal Pharyngitis Complications

Rheumatic fever

Rheumatic fever is exceedingly rare in the United States and other developed countries (annual incidence of less than one case per 100,000). This illness should be suspected in any patient with joint swelling and pain, subcutaneous nodules, erythema marginatum or heart murmur, and a confirmed streptococcal infection during the preceding month. Patients will have an elevated antistreptolysin- O titer and erythrocyte sedimentation rate.^[5]

Post-streptococcal glomerulonephritis

Post streptococcal glomerulonephritis is another rare complication of GABHS pharyngitis, although treatment with antibiotics does not prevent it. Patients present with hematuria and, frequently, edema in the setting of a recent streptococcal infection with an elevated antistreptolysin-O titer.^[5]

Scarlet fever

Scarlet fever is another complication of GABHS pharyngitis and usually presents as a rash characterized by punctate, erythematous, branch able, sandpaper-like exanthematous rash. Rash distributes in the neck, groin, and axillae, and accentuate specifically in the body folds and creases. Other findings include pharynx and tonsils appear erythematous and covered with exudates and tongue appears as bright red with white coating, also known as strawberry tongue.

Prognosis

Most cases of pharyngitis go away on their own without complications.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
↑ St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes. Mayo Clin Proc 81 (9):1172-6. PMID: 16970213
↑ Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55 (10):1279-82. DOI:10.1093/cid/cis847 PMID: 23091044
↑ ^5.0 ^5.1 ^5.2 ^5.3 ^5.4 ^5.5 Vincent MT, Celestin N, Hussain AN (2004) Pharyngitis. Am Fam Physician 69 (6):1465-70. PMID: 15053411
↑ ^6.0 ^6.1 ^6.2 ^6.3 Murray RC, Chennupati SK (2012). "Chronic streptococcal and non-streptococcal pharyngitis". Infect Disord Drug Targets. 12 (4): 281–5. PMID 22338589.

[pmid11172144-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144

[Mandell-2] Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.

[pmid16970213-3] St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes. Mayo Clin Proc 81 (9):1172-6. PMID: 16970213

[pmid23091044-4] Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55 (10):1279-82. DOI:10.1093/cid/cis847 PMID: 23091044

[pmid15053411-5] 5.0 ^5.1 ^5.2 ^5.3 ^5.4 ^5.5 Vincent MT, Celestin N, Hussain AN (2004) Pharyngitis. Am Fam Physician 69 (6):1465-70. PMID: 15053411

[pmid22338589-6] 6.0 ^6.1 ^6.2 ^6.3 Murray RC, Chennupati SK (2012). "Chronic streptococcal and non-streptococcal pharyngitis". Infect Disord Drug Targets. 12 (4): 281–5. PMID 22338589.

[1]

[2]

[3]

[4]

[5]

[6]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Pharyngitis}}
+{{CMG}};{{AE}} {{AA}}, {{VSKP}}
-{{CMG}}{{AE}}{{AA}}
+==Overview==
+The [[sore throat]], [[fever]], and [[malaise]] associated with acute [[pharyngitis]] are distressing, but with few exceptions, these illnesses are both [[benign]] and [[self-limited]]. Many [[Bacteria|bacterial]] and [[Virus|viral organisms]] are capable of inducing pharyngitis, either as a single manifestation or as part of a more generalized illness. History and symptoms are essential to diagnosis to identify the treatable causes (e.g., [[Group A streptococcal infection|GAS]]) to prevent complications.
 ==Natural History==
+*Acute pharyngitis is typically described as the triad of [[sore throat]], [[fever]], and pharyngeal inflammation characterized by [[erythema]] and [[edema]], although [[exudates]], [[vesicles]], or [[ulcerations]] may also be present.
+*Although pharyngitis may be a primary disorder, sore throat and [[pharyngeal erythema]] may also be prominent in systemic disorders, such as [[Human Immunodeficiency Virus (HIV)|acute retroviral syndrome]], or part of a more generalized [[upper respiratory tract infection]].
+*Most cases of acute [[pharyngitis]] are due to common [[viral]] infections and are [[benign]],[[self-limited]] processes.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
+*The appropriate recognition of patients with more complicated infections that require diagnostic evaluations and treatment is one of the challenges of [[primary care medicine]].<ref name= Mandell>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> An estimated 1-2% of acute pharyngitis progresses to recurrent or chronic disease.<ref name="pmid16970213">St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16970213 Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes.] ''Mayo Clin Proc'' 81 (9):1172-6. PMID: [https://pubmed.gov/16970213 16970213]</ref>
+*Patients with recurrent episodes of [[pharyngitis]] and more than one episode of [[streptococcal]] pharyngitis at close intervals associated with laboratory evidence of [[GAS]] pharyngitis consider that they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections.<ref name="pmid23091044">Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23091044 Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.] ''Clin Infect Dis'' 55 (10):1279-82. [http://dx.doi.org/10.1093/cid/cis847 DOI:10.1093/cid/cis847] PMID: [https://pubmed.gov/23091044 23091044]</ref>
 === '''Group A Streptococcus''' ===
-Symptoms develop after a short incubation period of 24 to 72 hours.<ref name="pmid15053411">Vincent MT, Celestin N, Hussain AN (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15053411 Pharyngitis.] ''Am Fam Physician'' 69 (6):1465-70. PMID: [https://pubmed.gov/15053411 15053411]</ref> Most cases of [[pharyngitis]] go away on their own without [[complications]]. Untreated, group A bete hemolytic streptococcus (GABHS) infection lasts seven to 10 days. Patients with untreated streptococcal pharyngitis are infectious during the acute phase of the illness and for one additional week. Effective antibiotic therapy shortens the infectious period to 24 hours, reduces the duration of symptoms by about one day, and prevents most complications.<ref name="pmid15053411" />
+*[[Strep pharyngitis]] occurs predominantly, though not exclusively, in school-age children.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
+*Symptoms develop after a short incubation period of 24 to 72 hours.<ref name="pmid15053411">Vincent MT, Celestin N, Hussain AN (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15053411 Pharyngitis.] ''Am Fam Physician'' 69 (6):1465-70. PMID: [https://pubmed.gov/15053411 15053411]</ref>
+*[[Symptoms]] can vary widely, with some patients experiencing the full effects of the [[syndrome]] while others, such as those who have undergone [[tonsillectomy]], may have milder symptoms.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
+*Untreated, [[Group A beta-hemolytic streptococci|group A beta-hemolytic streptococcus]] (GABHS) infection lasts 7-10 days. Patients with [[untreated]] streptococcal pharyngitis are infectious during the acute phase of the illness and for one additional week.
+*Effective [[antibiotic]] therapy shortens the [[infectious]] period to 24 hours, reduces the duration of symptoms by about one day, and prevents most [[complications]].<ref name="pmid15053411" />
 === Corynebacterium diphtheriae ===
-The incubation period for Corynebacterium diphtheriae infection is two to four weeks.<ref name="pmid15053411" />
+*The [[incubation]] period of [[Corynebacterium diphtheriae]] infection range between 2-4 weeks.<ref name="pmid15053411" />
+*[[Diphtheria]] common in children and primarily among unimmunized or poorly immunized members of socioeconomically disadvantaged groups.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
 ==Complications==
-Identifying the cause of pharyngitis, especially group A beta-hemolytic streptococcus (GABHS), is important to prevent potential life-threatening complications.<ref name="pmid15053411">Vincent MT, Celestin N, Hussain AN (2004) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15053411 Pharyngitis.] ''Am Fam Physician'' 69 (6):1465-70. PMID: [https://pubmed.gov/15053411 15053411]</ref> Serious complications of pharyngitis may include peritonsillar abscess or retropharyngeal abscess.<ref>{{cite book | last = Cohen | first = J | title = Infectious diseases | publisher = Mosby/Elsevier | location = Edinburgh | year = 2010 | isbn = 978-0323045797 }}</ref>Complicationsof [[pharyngitis]] based on the causing agent include the following: <ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589  }} </ref>
+Identifying the cause of pharyngitis, especially [[Group A streptococcal infection|GABHS]], is important to prevent potential [[life-threatening]] [[complications]].☃☃ Serious complications of pharyngitis may include [[peritonsillar abscess]] or [[retropharyngeal abscess]].☃☃ Complications of [[pharyngitis]] based on the causing agent include the following: <ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589  }} </ref>
 {| style="border: 0px; font-size: 90%; margin: 3px;" align=center
@@ Line 26: / Line 38: @@
 *[[Tonsillar abscess]]<ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589  }} </ref>
 *[[Sinusitis]]
-*Otitis media
+*[[Otitis media]]
 *[[Necrotizing fasciitis]]
 *[[Meningitis]]
-*Jugular vein thrombophlebitis
+*[[Jugular vein]] [[thrombophlebitis]]
-'''Non suppurative complications'''
+'''Non-suppurative complications'''
 *[[Acute rheumatic fever]] (ARF)<ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589  }} </ref>
 *[[Scarlet fever]]
-*Streptococcal toxic shock syndrome<ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589  }} </ref>
+*Streptococcal [[toxic shock syndrome]]<ref name="pmid22338589">{{cite journal| author=Murray RC, Chennupati SK| title=Chronic streptococcal and non-streptococcal pharyngitis. | journal=Infect Disord Drug Targets | year= 2012 | volume= 12 | issue= 4 | pages= 281-5 | pmid=22338589 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22338589  }} </ref>
 *Acute [[glomerulonephritis]] ([[Post-streptococcal glomerulonephritis]])<ref name="pmid15053411" />
-*Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)
+*Pediatric [[autoimmune]] [[neuropsychiatric]] disorder associated with [[group A streptococci]] (PANDAS)
 |-
 | style="padding: 5px 5px; background: #DCDCDC;" |'''Influenza'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Pneumonia
+*[[Pneumonia]]
-*Encephalitis
+*[[Encephalitis]]
-*Aseptic meningitis
+*[[Aseptic meningitis]]
-*Guillain barre syndrome
+*[[Guillain-Barre syndrome]]
 *[[Transverse myelitis]]
-*[[Myositis]] and rhabdomyolysis
+*[[Myositis]] and [[rhabdomyolysis]]
 |-
 | style="padding: 5px 5px; background: #DCDCDC;" |'''Adenovirus'''
@@ Line 50: / Line 62: @@
 *[[Laryngotracheitis]]
 *[[Bronchitis]]
-*Pneumonia
+*[[Pneumonia]]
 *[[Otitis media]]
-*Meningoencephalitis
+*[[Meningoencephalitis]]
 *[[Hepatitis]]
-*Myocarditis
+*[[Myocarditis ]]
 *[[Nephritis]]
-*Neutropenia
+*[[Neutropenia]]
 *[[Disseminated intravascular coagulation]]
 |-
 | style="padding: 5px 5px; background: #DCDCDC;" | '''Cocksackie A virus'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Aseptic [[meningitis]]
+*[[Aseptic]] [[meningitis]]
-*Myocarditis
+*[[Myocarditis]]
-*Acute flaccid paralysis
+*[[Acute flaccid paralysis]]
-*Conjunctival ulceration
+*[[Conjunctival ulceration]]
-*Brainstem [[encephalitis]]
+*[[Brainstem]] [[encephalitis]]
 |-
-| style="padding: 5px 5px; background: #DCDCDC;" |'''Ebstein barr virus'''
+| style="padding: 5px 5px; background: #DCDCDC;" |'''Epstein barr virus'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Airway obstruction
+*[[Airway obstruction]]
-*Splenic rupture
+*[[Splenic rupture]]
-*X-linked lymphoproliferative disease
+*[[X-linked lymphoproliferative disease]]
-*Lymphomatoid granulomatosis
+*[[Lymphomatoid granulomatosis]]
 |-
-| colspan="3" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Less common complications'''}}
+| colspan="2" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Less common complications'''}}
 |-
 | style="padding: 5px 5px; background: #DCDCDC;" | '''Gonococcus'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Disseminated gonorrhea
+*[[Disseminated gonorrhea]]
 *[[Meningitis]]
 *[[Endocarditis]]
@@ Line 84: / Line 96: @@
 | style="padding: 5px 5px; background: #DCDCDC;" | '''Diphtheria'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Airway obstruction
+*[[Airway obstruction]]<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
 *[[Myocarditis]]
 *[[Polyneuropathies]]
-** 10th cranial nerve disorder
+** [[10th cranial nerve disorder]]
-** 9th cranial nerve disorder
+** [[9th cranial nerve disorder]]
 ** [[Peripheral motor neuropathy]]
-* Diaphragm paralysis
+* [[Diaphragm paralysis]]
-* Neurogenic bladder dysfunction
+* [[Neurogenic bladder dysfunction]]
 * [[Acute renal failure ]]
 * [[Septicemia]]
@@ Line 107: / Line 119: @@
 | style="padding: 5px 5px; background: #DCDCDC;" | '''Parainfluenza virus'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Retropharyngeal abcess
+*[[Retropharyngeal abscess]]
 *[[Pneumonia]]
 |-
@@ Line 115: / Line 127: @@
 === Rheumatic fever ===
-Rheumatic fever is exceedingly rare in the United States and other developed countries (annual incidence less than one case per 100,000). This illness should be suspected in any patient with joint swelling and pain, subcutaneous nodules, erythema marginatum or heart murmur, and a confirmed streptococcal infection during the preceding month. Patients will have an elevated antistreptolysin- O titer and erthrocyte sedimentation rate.<ref name="pmid15053411" />
+[[Rheumatic fever]] is exceedingly rare in the United States and other developed countries (annual incidence of less than one case per 100,000). This illness should be suspected in any patient with joint swelling and pain, [[subcutaneous]] [[nodules]], [[erythema marginatum]] or [[heart murmur]], and a confirmed streptococcal infection during the preceding month. Patients will have an elevated [[ASO titer|antistreptolysin- O titer]] and [[ESR|erythrocyte sedimentation rate]].<ref name="pmid15053411" />
-=== Post streptococcal glomerulonephritis ===
+=== Post-streptococcal glomerulonephritis ===
-Post streptococcal glomerulonephritis is another rare complication of GABHS pharyngitis, although treatment with antibiotics does not prevent it. Patients present with hematuria and, frequently, edema in the setting of a recent streptococcal infection with an elevated antistreptolysin-O titer.<ref name="pmid15053411" />
+[[Post-streptococcal glomerulonephritis|Post streptococcal glomerulonephritis]] is another rare complication of [[GABHS|GABHS pharyngitis]], although treatment with antibiotics does not prevent it. Patients present with [[hematuria]] and, frequently, [[edema]] in the setting of a recent streptococcal infection with an elevated [[ASO|antistreptolysin-O titer]].<ref name="pmid15053411" />
 === Scarlet fever ===
-Scarlet fever is associated with GABHS pharyngitis and usually presents as a punctate, erythematous, blanchable, sandpaperlike exanthem. The rash is found in the neck, groin, and axillae, and is accentuated in body folds and creases (Pastia’s lines). The pharynx and tonsils are erythematous and covered with exudates. The tongue may be bright red with a white coating (strawberry tongue).
+Scarlet fever is another complication of [[Group A streptococcal infection|GABHS]] pharyngitis and usually presents as a [[rash]] characterized by punctate, [[erythematous]], branch able, sandpaper-like [[exanthematous]] [[rash]]. Rash distributes in the neck, [[groin]], and [[axillae]], and accentuate specifically in the body folds and creases. Other findings include pharynx and tonsils appear erythematous and covered with exudates and tongue appears as bright red with white coating, also known as [[strawberry tongue]].
 ==Prognosis==
 Most cases of [[pharyngitis]] go away on their own without [[complications]].
 ==References==
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-[[Category:Needs overview]]
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