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What is Post-transplant lymphoproliferative disorder? What is the relationship between PTLD and tonsils?
Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening complication that follows solid organ or bone marrow transplant. The first symptoms are often nonbacterial tonsillar inflammation or hypertrophy associated with an EBV infection. Tonsillectomy combined with tapering of immunosuppression offers the best chance for a complete recovery.
Symptoms of the most common bacterial tonsillar infection.
Strep throat (GABHS): more sudden onset than viral, headache, typically not associated with a cough or rhinorrhea, high-grade fever, tonsillar/palatal petechiae (also seen in mononucleosis), exudative tonsils, tender anterior cervical adenopathy.
How do you diagnose rheumatic fever?
- Modified Jones Criteria, must have a previous streptococcal infection + 2 major Jones criteria or 1 major and 2 minor criteria
- Major Jones Criteria: carditis (cardiomegaly. valvular disease, CHF). migratory polyarthritis (occurs 2-6 weeks after initial infection), subcutaneous nodules (Aschoff bodies), erythema marginatum (serpiginous rash), chorea
- Minor Jones Criteria: arthralgia, fever, elevated acute phase reactants (eRP, ESR), prolonged PR interval.
Treatment of rheumatic fever
- Treat GABHS infection
- NSAIDs and corticosteroids
- may require cardiac medications as well as haloperidol for chorea
Describe the pathophysiology of rheumatic fever.
- Local invasion causes release of extracellular toxins.
- M proteins are similar to myocardial sarcolemma antigens
Describe the diagnosis and treatment of post-streptococcal glomerulonephritis.
- Positive streptococcal tests (cultures, antibodies), urine analysis (proteinuria, hematuria, and urinary casts), reduced complement (decreased C3); renal biopsy rarely required
- Supportive medical management (antihypertensives, diuretics, fluid restriction, nephrology consultation), antimicrobial management for GABHS.
- Usually self-limited, resolves in 3 months.
What is adenoid facies?
In children whose mouth breathing is untreated may develop long, narrow faces (hypoplastic maxilla), narrow mouths, high palatal vaults, dental malocclusion, gummy smiles (short upper lip).
What is the physiologic reason children with OSA sometimes have enuresis? Is adenotonsillectomy an effective treatment?
- Bedwetting may be due to the increased arousal
- Children with OSAS and Bedwetting have elevated levels of brain natriuretic peptide
- Surgical treatment of upper airway obstruction by T & A is associated with complete resolution of nocturnal enuresis in 31-76% of children within several months of surgery.
When is overnight admission recommended after T&A?
- OSA <3 y/o or
- Severe OSA (AHI> 10 or O2 nadir <80%)
- In a large review, 9.8% of children younger than age 3 experienced a respiratory complication postoperatively as compared to 4.9% of children age 3-6. A second study showed outpatient tonsillectomy was less cost-effective than hospital admission for kids under 3, primarily due to prolonged recovery room stays.
What medications should be given intraoperatively at the time of tonsillectomy?
- Decadron (strong recommendation)
- No antibiotics (strong recommendation)
By PSG, How is OSA graded in adults and kids?
- Kids - AHI<1: normal, AHI 1-5: mild, AHI 5-10: moderate, AHI >10: severe
- Adults - AHI + RERA <5: normal; 5-15: mild; 15-30: moderate; >30: severe
What is the arterial supply to the tonsils?
- Lingual artery -> dorsal lingual branch (lower pole)
- Facial artery -> ascending palatine and tonsillar arteries (main supply, lower pole)
- Ascending pharyngeal artery (upper pole)
- Maxillary artery -> greater palatine and descending palatine arteries (upper pole)
Which immune cells predominate in the three tonsillar zones (Reticular cell epithelium, extrafollicular area, and lymphoid follicle)?
- Reticular cell epithelium: antigen-presenting M cells transport antigen to lymphoid germinal center
- extrafollicular area: T cells
- lymphoid follicle: composed of the mantle zone (mature B cells) and the germinal center (active B cells)
At what age are tonsils and adenoids typically largest?
- Grow from 1-3 years (after exposure to androgens)
- Peak between 3-7 years
- Involute after puberty
What percentage of pharyngitis is viral?