Vincent infection or trench mouth is a fulminant form of acute necrotizing ulcerative gingivitis with synergistic infection with certain spirochetal organisms, notably Treponema vincentii, with anaerobic Selenomonas and Fusobacterium. Vincent angina refers to a virulent form of anaerobic pharyngitis; gray pseudomembranes are found on the tonsils. Lemierre syndrome is acute pharyngitis complicated by thrombosis of the internal jugular vein and septic emboli (most often to the lungs). It occurs primarily in adolescents and is caused by Fusobacterium necrophorum.
Ludwig angina is a mixed anaerobic bacterial cellulitis of the submandibular and sublingual regions. Although often applied to any infection of the sublingual or submandibular region, the term originally was reserved for a rapidly spreading bilateral cellulitis of the sublingual and submandibular spaces. It typically is due to spreading from a periapical abscess of the second or third mandibular molar. It also has been associated with tongue piercing. A propensity for rapid spread, glottic and lingual swelling, and consequent airway obstruction makes prompt intervention imperative.
A syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis is a rare cause of recurrent fever in children. Recurring nonspecific pharyngitis is accompanied by fever and painful solitary vesicular lesions in the mouth. The fevers begin at a young age (usually <5 years). Episodes last approximately 5 days, with a mean of 28 days between episodes. Episodes are shorter with oral prednisone and unresponsive to nonsteroidal anti-inflammatory drugs or antibiotics. The syndrome resolves in some but persists in other children. Long-term sequelae do not develop.
Even if untreated, most episodes of streptococcal pharyngitis resolve uneventfully over a few days. Early antimicrobial therapy accelerates clinical recovery by 12 to 24 hours. The major benefit of antimicrobial therapy is prevention of acute rheumatic fever (see Chapter 146). Because the latent (incubation) period of acute rheumatic fever is relatively long (1 to 3 weeks), treatment instituted within 9 days of illness is virtually 100% successful in preventing rheumatic fever. Treatment begun more than 9 days after the onset of illness, although less than 100% successful, has some preventive value. Antibiotic therapy should be started promptly in children with a positive rapid test for group A streptococcus, scarlet fever, symptomatic pharyngitis whose sibling has documented streptococcal pharyngitis, a past history of rheumatic fever or a recent family history of rheumatic fever, or symptomatic pharyngitis and living in an area experiencing an epidemic of acute rheumatic fever or poststreptococcal glomerulonephritis.
A variety of antimicrobial agents can be used to treat streptococcal pharyngitis (Table 103-2). Cephalosporins have superior pharyngeal bacterial eradication rates compared to
Oral penicillin V (2–3 times daily for 10 days) 10 mg/kg/dose, maximum dose 250 mg/dose Intramuscular benzathine penicillin G (single dose) For children ≤27 kg: 600,000 U For larger children and adults: 1.2 million U
For persons allergic to penicillin
Cephalexin 20 mg/kg/dose BID, maximum dose 500 mg/dose × 10 days
Cefadroxil 30 mg/kg OD maximum, maximum dose 1 g × 10 days
Clindamycin 7 mg/kg/dose TID, maximum dose 300 mg/dose × 10 days