Question of the Week - July

July 12, 2023

Question: A 9-year-old boy is brought in to the clinic by his mother with a sore throat for the past 3 days. He has a fever and has not been able to eat due to the pain, though he is able to tolerate liquids. His mother denies cough, hoarseness, rashes, or other related symptoms. He is allergic to penicillin. He is febrile to 101.6ºF. Vital signs are otherwise stable. Physical examination of the mouth reveals swollen tonsils covered in exudate bilaterally and neck tenderness upon palpation. Otologic exam is normal and auscultation of the chest is unremarkable. What is the most appropriate next step in management for this patient?

 

A. Urgent admission to hospital

B. Amoxicillin for 10 days

C. Obtain rapid strep test

D. CT of head and neck

E. Metronidazole for 7 days

  • Correct Answer: C

    Explanation: The Centor criteria may be used to identify cases of tonsillitis more likely to be bacterial: 3-14 years old (+1), tonsillar exudate (+1), history of fever > 100.4ºF (+1), and absent cough (+1). Scores ≥ 2 warrant rapid strep test and/or throat culture. In select patients with scores ≥ 4, empiric antibiotic therapy may be considered; however, 2012 IDSA guidelines do not recommend empiric antibiotic therapy without confirmatory testing. Hospital admission is unnecessary unless the patient experiences worsening symptoms, such as stridor or inability to tolerate fluids as well as solids. If antibiotics are indicated, phenoxymethylpenicillin for 10 days is the treatment of choice, unless the patient has a penicillin allergy.

    References:

    Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2012; 55(10): p.e86–e102. doi: 10.1093/cid/cis629.

July 26, 2023

A 42-year-old male presents to your clinic with a thyroid nodule discovered during a routine health check-up. The nodule is non-tender, well-defined, and measures approximately 1.5 cm in diameter. On palpation, there are no cervical lymph nodes detected. The patient's thyroid-stimulating hormone (TSH) level is within the normal range. The ultrasound of the thyroid nodule reveals the following characteristics: hypoechoic, microcalcifications, irregular  margins, and taller-than-wide shape. There is no evidence of extrathyroidal extension or suspicious lymphadenopathy. Based on the ultrasound findings and applying the Thyroid Imaging Reporting and Data System (TIRADS), what is the most appropriate next step in the work-up of this patient's thyroid nodule?

A). TIRADS 3, no further work up necessary

B). TIRADS 5, follow with serial imaging

C). TIRADS 5, fine needle biopsy the lesion

D). TIRADS 3, follow with serial imaging

E). TIRADS 4, fine needle biopsy the lesion

  • Correct Answer: C

    Explanation: The Thyroid Imaging Reporting and Data System (TIRADS) is a risk stratification system used to categorize thyroid nodules based on their ultrasound features. It helps to standardize reporting and provides guidance for managing thyroid nodules based on their likelihood of malignancy.

    TIRADS classifies thyroid nodules into different categories, ranging from TIRADS 1 (benign) to TIRADS 5 (highly suspicious for malignancy). The categories are determined by evaluating specific ultrasound features of the nodule, such as echogenicity, shape, margins, presence of calcifications, and other characteristics. See table below.

    Based on the ultrasound findings provided, the patient's thyroid nodule would likely be classified as TIRADS 5.

    TIRADS 5 refers to a category of thyroid nodules with highly suspicious ultrasound features, which are associated with a high risk of malignancy. In this case, the presence of multiple suspicious features such as being hypoechoic, having microcalcifications, irregular margins, and a taller-than-wide shape would lead to the nodule being categorized as TIRADS 5.

    As mentioned earlier, a TIRADS 5 classification indicates a high likelihood of malignancy, which is why a thyroid fine-needle aspiration (FNA) biopsy is the most appropriate next step in the work-up to further evaluate the nature of the nodule and determine if it is benign or malignant.

    References:

    Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, Cronan JJ, Beland MD, Desser TS, Frates MC, Hammers LW, Hamper UM, Langer JE, Reading CC, Scoutt LM, Stavros AT. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017 May;14(5):587-595. doi: 10.1016/j.jacr.2017.01.046. Epub 2017 Apr 2. PMID: 28372962. [Article Link]