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  See discussions, stats, and author profiles for this publication at: Pharyngitis and sore throat: A review  Article   in  AFRICAN JOURNAL OF BIOTECHNOLOGY · July 2011 CITATION 1 READS 1,463 9 authors , including: Some of the authors of this publication are also working on these related projects: Sof t sets   View projectsuperalgebras   View projectMuhammad AkramUniversity of the Punjab 396   PUBLICATIONS   3,183   CITATIONS   SEE PROFILE Muhammad Asif The Islamia University of Bahawalpur 79   PUBLICATIONS   540   CITATIONS   SEE PROFILE Dr Syed Mohammad Ali ShahGovernment College University Faisalabad 70   PUBLICATIONS   255   CITATIONS   SEE PROFILE Ghazala ShaheenThe Islamia University of Bahawalpur 18   PUBLICATIONS   100   CITATIONS   SEE PROFILE All content following this page was uploaded by Muhammad Riaz Ur Rehman on 20 June 2017. The user has requested enhancement of the downloaded file.  African Journal of Biotechnology Vol. 10(33), pp. 6190-6197, 6 July, 2011 Available online at DOI: 10.5897/AJB10.2663 ISSN 1684–5315 © 2011 Academic Journals Review Pharyngitis and sore throat: A review Aamir Somro 1 , Muhammad Akram 1 *, M. Ibrahim khan 1 , H. M. Asif 2 , 1 Abdul Sami, S. M. Ali Shah 2 , Ghazala Shahen 2 , Khalil Ahmed 2  and Riaz Ur Rehman 2   1 Shifa ul Mulk Memorial Hospital, Faculty of Eastern Medicine, Hamdard University, Karachi, Pakistan. 2 College of Conventional Medicine, Islamia University, Bahawalpur, Pakistan. Accepted 17 March, 2011 Pharyngitis is a sore throat caused by inflammation of the back of the throat. It is one of the most common reasons for visits to family physicians. Throat may be scratchy and swallowing can be painful. Usually, a sore throat is the sign of another illness, such as a cold or the flu. In this review article, epidemiology, national perspective, regional perspective, pathogenesis, clinical diagnosis, clinical presentation and causes of pharyngitis was described. Key words:  Pharyngitis, sore throat, inflammation. INTRODUCTION Among the many infections that confront clinicians every day, there is probably no more common and yet contro-versial one than acute pharyngitis caused by group A β -hemolytic streptococcus ( Streptococcus pyogenes  ) and viruses (Susan et al., 2001). This illness concerns clinicians because not only is it an acute illness for an individual patient, but the potential spread of the organism and the resulting public health implications cannot be ignored either. At the outset of the 21st century, the acute pharyngitis and sore throat was unique and to date, the clinical management of these upper respiratory tract infections remains controversial. The clinical diagnosis is not specific. Laboratory data can be misleading and frequently misinterpreted. Epidemio-logical evidence suggests that the complexities and the controversies of these infections remain uncontrolled in all populations (Mcfarlane et al., 1998). A sore throat affects a person in many ways and the symptoms vary from one individual to another. Accor-dingly, some describe the peculiar symptoms of the disorder as a burning sensation, while others feel a tickling or scratchy sensation in the throat. By and large, a sore throat affects the person as a general sore feeling that starts at the back of the oral cavity, gradually spreading out into the region of the middle throat; these *Corresponding author. E-mail: Tel: 92-021-6440083. Fax: 92-021-6440079. symptoms are generally felt along with varying degrees of pain in individual cases. A sore throat can usually be seen more as a symptom of another illness and arises as a result of inflammation in the sensitive tissues of the throat. The body responds by increasing the rate of circulation of blood in the throat as soon as the initial inflammation or irritation has begun. Therefore, the swelling and the pain felt in the throat and the subsequent reddening of the tissues is an actual reaction of the immune system, as the increase in the circulating blood transports and increased load of white blood cells and other substances to counter the initial infection, therefore, the actual symptoms present are merely signs that the body is fighting back the infection (Wiesner et al., 1973). Some of the usual causative agents of soreness in the throat-or the real triggers of the condition-are primary physiological reactions such as allergies, environmental factors such as dust and smoke and low humidity also play important roles. Additionally, soreness in the throat can be experienced as a result of viral infections and infection by other pathogens such as bacteria; the body may react to all of these factors and thus trigger the soreness in the throat. External events such as the draining of excessive mucus from the nose and from the sinuses down the back of the throat and even things like a postnatal drip are often followed by soreness in the throat and in such cases, the sore throat usually arises because of infection from viral sources or from an allergic reaction of the body to these physical intrusion.   Moreover, the sensitive tissues in the throat are primary targets for the viruses that bring about colds and other throat infections. It normally takes several days at a stretch and a persistent infection for the development of a virally caused soreness in the throat. There are also diffe-rences in the way different sore throat causing pathogens elicit symptoms from the affected individual, for example viral infections commonly persist for longer periods but are comparatively mild to moderate in the symptoms that they bring about viz a viz bacterial infection (Andersson et al., 1987). Bacterial infections often strike suddenly and can bring out acute symptoms and give a lot of dis-comfort to the individual, a good example is strep throat, and this type of bacterial infection can quickly establish itself over some hours. Bacteria infect abruptly generate symptoms such as severe pain in the throat and other uncomfortable physical symptoms such as difficulty in swallowing; the presence of fever is also typical of bacterial infections (Glezen et al., 1957). EPIDEMIOLOGY Pharyngitis is prevalent all over the world, more com-monly in temperate climates especially during the winter and early spring months. In the United States, acute res-piratory tract infections in 1998 resulted in an estimated 84 million visits to physicians; of which 25 million were due to upper respiratory tract infection. According to the National Ambulatory Medical Care Survey, upper respiratory tract infections, including acute pharyngitis, are responsible for 200 visits to a physician per 1000 population annually in the United States (Peltola, 1982; Gonzales, 2001). CLIMATOLOGICAL SETTINGS From the tropics to the arctic, climate and weather have powerful direct and indirect impacts on human life. People adapt to the conditions in which they live, and human physiology can handle substantial variation in weather. Changes in climate are likely to lengthen the transmission seasons of important vector borne diseases. The epidemiology of pharyngitis derives largely from studies conducted mostly in the Northern or the tem-perate climate countries where pharyngitis is a common complain. In the tropical countries (mostly, though not in all), there are few prospective studies that provide data on pharyngitis, its epidemiology and clinical presentation. As a result, it is problematic to determine the magnitude of true differences between geographic settings, and to assess if apparent differences are related to geographic/ climatological or other factors (Hendrix et al., 1999). Long term studies in North America show the proportion of pharyngitis, that is, streptococcal has not varied for over 50 years, although the incidence of rheumatic fever and rheumatic carditis have declined remarkably. Somro et al. 6191 SOCIOECONOMIC SETTING There is a vast difference between the lifestyles of individuals from the high income and those from the low income population at large which reflects in the health of those individuals. The individuals from the high income bracket are in a position to exercise multiple options in addressing their health issues, like attending tertiary care centers or clinics from the private sector and can gain access to costly diagnostic tools as opposed to those individuals from the lower income population (Gonzales et al., 2001). The crowded living style of the low income population accentuates further their risk of contacting disease by their excessive exposure to infectious diseases that are spread by droplet. Usually, in the low income living areas, there are limited diagnostic facilities which are of course inadequate for the number of individuals living there, which further hampers the possibility of early diagnosis of disease and in turn does not allow that sector of the population to obtain early treatment or resolution of their disease by treatment where the needed diagnostic and treatment facilities themselves are grossly inadequate (Kaplan et al., 1972). HIGH INCOME COUNTRIES In high-income countries, pharyngitis is common in children ages 3 to 15 years. On average in the USA, each child has approximately one GABHS pharyngitis infection by age 5, with a mean of 3 episodes (range 108) by 13 years of age. After the availability of penicillin, the incidence of acute rheumatic fever (ARF) declined by 50%. From 1935 to 1960, the incidence of acute rheu-matic fever in the USA ranged between 40 and 65/100,000 in all age groups. From the late 1960s, there was a marked decline in acute rheumatic fever, and since 1970, incidence of rheumatic fever has ranged from 0.023 to 1.88 per 1000,000 populations (Dajani et al., 1995). LOW-INCOME COUNTRIES Few studies have been conducted to ascertain the inci-dence and prevalence of GABHS in developing countries. The studies were non-standardized with regards to the laboratory investigation methods for throat culture diagnosis (Schwartz et al., 1985). Few precise estimates of the incidence of GABHS pharyngitis in low income countries are available. The reported incidence of culture-proven GABHS pharyngitis in prospective studies in a few sites appears to be much higher than that reported from the United States in the1950s: up to 900 versus approximately 200 per 1,000 child-years of observation (US Census, 2004).  6192 Afr. J. Biotechnol. NATIONAL PERSPECTIVE Pakistan is a developing country and has poor health indicators. It ranks 136th of the 177 countries on the Human Development Index of the United Nations of 2007-2008 (US Census, 2004). In Pakistan, over a third of the people are living in poverty and have a fragile health structure; many patients cannot afford the costly treatment (US Census, 2004). The NHDR/PIDE 2001 Survey and the National Health Survey of Pakistan data show that from the low income persons of 45 years and above, as many as 45% suffer from poor health and 80% suffer from poor-to-fair health. Usually, the low income individuals are more suscep-tible to disease due to inadequate nutrition which of course lowered the individual’s immunity. Moreover, the lack of access to safe drinking water as well as un-hygienic conditions of consumption, storage and produc-tion of food would be expected to result in a relatively high frequency of infection disease amongst the poor (Poses et al., 1985). The respiratory tract infections are common in children as well as in adults. The estimated incidence of respire-tory infections in children and adults are 1192 visits to the physicians per 2000 population per annum. According to the National Health Survey, upper respiratory tract infection including pharyngitis and sore throat are respon-sible for 800 visits to a physician per 2000 population annually in Pakistan (US Census, 2004; WHO, 2008). REGIONAL PERSPECTIVE Karachi is the largest city and the economic hub of Pakistan with an estimated population of 10 million people of diverse ethnic and socioeconomic groups. The metropolitan area along with its suburbs comprises the world's second most populated city, which spread over 3,530 km 2  (US Census, 2004). The city credits its growth to the mixed populations of economic and political mig-rants and refugees from different national, provincial, linguistic and religious srcins that have largely come to settle here permanently. In Karachi, like other regions of Pakistan, acute phary-ngitis and sore throat is very common and frequent, and peak seasons for sore throat and acute pharyngitis are winter and early spring (November to April). Air pollution due to peripheral industrial area and a great number of automobiles in the Karachi city increases the risk of viral and/or bacterial sore throat and pharyngitis as well. PATHOGENESIS OF INFECTIOUS DISEASES Unani perspective: Pathogenesis In the Unani system of medicine, the concept of tempe- rament is a main procedure of diagnosis (Galen, 1997; Ahmed et al., 1980). Temperament is regarded as a measure of equilibrium or homeostasis which exists at different levels of complexity in the body, starting at the simple cell, and passing through tissue and organs and complex organ systems, to the whole person, and how the individual interacts with the external environment. Temperament along with the humours (Akhlat) also protects the body from diverse types of offences as it maintains the optimal level of immunity and helps maintain the defense mechanism of the body (Breese et al., 1954). The taking of personal history as part of the temperamental evaluation is very important because at the end of this in-depth assessment, a person's dominant and subdominant temperament is determined. This provides guidelines for both the subsequent treatment of the clinical disorder, and the prevention of the disorder’s recurrence. In Unani medicine, the concept of cause relates to the etiology from which srcinates the existence or outcome of a certain state of the human body, is a state of health or disease. Ibn Sina describes three conditions for a cause to produce an effect. These conditions are: A. The cause must have sufficient active power to produce an effect. B. There must be a sufficient receptive component for the cause to have an effect. C. There has to be an appropriate period of contact between the active power and the receptive component. He further elaborated on four kinds of causes: A. Those associated with the humours/body fluids B. Those associated with the temperament C. Those associated with the governing/lifestyle factors D. Those associated with the functions of the body. These principles of cause and effect provide valuable insights to the understanding of all the pathological processes that take place within the body (Young et al., 1978). The concept of a single cause of a disease, whether it is a microbe, toxin or any other factor is not reasonable. Common sense and logic stress that every morbid condition is the result of many factors, occurring in com-bination, either sequentially or simultaneously. The existence of pathogenic organisms is expected, because this is the srcinal imbalance in temperament which provides an altered biotic environment in the living tissue in which bacteria, viruses and other microbes can thrive. This growth of microbes in the internal environment provokes a reaction from physis on the affected tissues; this reaction often manifests as symptoms of infection if the disease state becomes established. It is acknow-ledged that the microbes or germs do have a role in the
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