Clinical Features - Upper Respiratory Tract Infections and Stomatitis

CLINICAL FEATURES

Rhinitis is the most common manifestation of the common cold. It is characterized byvariable fever, inflammatory edema of the nasal mucosa, and an increase in mucous se-cretions. The net result is varying degrees of nasal obstruction; the nasal discharge may be clear and watery at the onset of illness, becoming thick and sometimes purulent as the infection progresses over 5 to 10 days.

Pharyngitis and tonsillitis are associated with pharyngeal pain (sore throat) and theclinical appearance of erythema and swelling of the affected tissues. There may be exu-dates, consisting of inflammatory cells overlying the mucous membrane, and petechial hemorrhages; the latter may be seen in viral infections but tend to be more prominent in bacterial infections. Viral infections, particularly herpes simplex, may also lead to the formation of vesicles in the mucosa, which quickly rupture to leave ulcers. Pharyngeal candidiasis can also erode the mucosa under the plaques of “thrush.” On rare occasions, the local inflammation may be sufficiently severe to produce pseudomembranes, which consist of necrotic tissue, inflammatory cells, and bacteria. This finding is particularly common in pharyngeal diphtheria, but may be mimicked by fusospirochetal infection (Vincent’s angina) and sometimes by infectious mononucleosis. In acute tonsillitis or pharyngitis of any etiology, regional spread of the infecting agents with inflammation and tender swelling of the anterior cervical lymph nodes is also common.

Stomatitis is inflammation of the oral cavity. Multiple ulcerative lesions of the oralmucosa, seen most frequently with severe primary herpes simplex infections, may extend to the tongue, lips, and face. In extreme cases, the pain may be so severe that the patient requires relief with topical anesthetics during the usual 9- to 12-day period of acute symptoms. Candida species can also invade oral surfaces to produce plaques identical to those of pharyngeal thrush. This infection is particularly common in young infants and immunocompromised individuals of any age.

Aphthous stomatitis is a recurrent disease of the oral mucosa characterized by singleor multiple painful ulcers with irregular margins, usually 2 to 10 mm in diameter. Healing usually occurs in a few days. The term commonly used to describe this condition iscanker sore. The cause is unknown. It can easily be confused with recurrent herpes sim-plex lesions and, like herpes, tends to recur in relation to stress, menses, local trauma, and other nonspecific stimuli.

A severe, gangrenous stomatitis that progresses beyond the mucous membranes to involve soft tissues, skin, and sometimes bone can complicate a variety of acute ill-nesses in patients who are severely debilitated and whose oral hygiene is poor. This infection, callednoma or cancrum oris, is rarely seen in the United States. Typical cases occur among children with severe protein – calorie malnutrition or other immune compromise. Measles sometimes precipitates noma. Etiologic agents thought to be involved includeFusobacterium and Bacteroides species, as well as Pseudomonasaeruginosa. Milder forms of stomatitis are seen in a variety of other common viralinfections. Examples include Koplik’s spots in measles, buccal or palatal ulcers in chickenpox, and similar phenomena in some enteroviral infections such as hand, foot, and mouth disease.

Peritonsillar or retrotonsillar abscesses are usually a complication of tonsillitis. They are manifested by local pain, and examination of the pharynx reveals tonsillar asymmetry with one tonsil usually displaced medially by the abscess. This infection is most common in children more than 5 years of age and in young adults. If not properly treated, the ab-scess may spread to adjacent structures. It can involve the jugular venous system, erode into branches of the carotid artery to cause acute hemorrhage, or rupture into the pharynx to produce severe aspiration pneumonia.

Retropharyngeal or lateral pharyngeal abscesses occur most frequently in infants and children less than 5 years of age. They can result from pharyngitis or from accidental per-foration of the pharyngeal wall by a foreign body. The infection is characterized by pain, inability or unwillingness to swallow, and, if the pharyngeal wall is displaced anteriorly near the palate, a change in phonation (nasal speech). The neck may be held in an ex-tended position to relieve pain and maintain an open upper airway. Examination of the pharynx usually reveals anterior bulging of the pharyngeal wall; if this finding is not ap-parent, lateral x-rays of the neck may demonstrate a widening of the space between the cervical spine and the posterior pharyngeal wall. The complications of such abscesses are basically the same as those described for peritonsillar abscesses; in addition, the suppura-tive process can extend posteriorly to the cervical spine to produce osteomyelitis or infe-riorly to cause acute mediastinitis.

In the immunocompromised patient, all of the various forms of stomatitis and pharyngitis described previously can be accentuated. Leukemia, agranulocytosis, chronic ulcerative colitis, congenital or acquired immunodeficiency (eg, AIDS), and treatment with cytotoxic or immunosuppressive drugs are commonly associated with such lesions. The marked damage to mucosal tissues that sometimes occurs can provide a portal of entry into deeper structures and then to the systemic circulation, creating a risk of bacterial or fungal sepsis. Conversely, oral lesions may also result from dissemi-nation of infection from other remote sites. Examples include disseminated histoplasmo-sis and sepsis caused by Pseudomonas species.