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Tonsillitis

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Tonsillitis

T
onsillitis is a condition that is commonly encountered in primary care. On
average 50 per 1000 patients consult their GP each year with a sore throat.
Tonsillitis is a significant economic burden, with 35 000 000 days lost from
work or school. Acute tonsillitis commonly affects children from the age of
4 years (highly prevalent between 4 and 8 years old) and young adults aged
between 15 and 25 years old. With the emergence of multi-resistant pathogens,
antimicrobial stewardship has become central to the strategies adopted by the
National Institute for Health and Care Excellence in the UK.

The GP curriculum and tonsillitis

Clinical module 3.15: Care of people with ENT, oral and facial problems lists the core competencies a GP
should acquire, to appropriately manage tonsillitis in the community. In particular, GPs should be able to:
. Manage primary contact with patients who have a common/important ENT, oral or facial problem, e.g. vertigo or
tinnitus
. Demonstrate knowledge of the scientific backgrounds of symptoms, diagnosis and treatment of ENT, oral and
facial conditions
. Understand how to recognise rarer but potentially serious conditions such as oral, head and neck cancer
. Understand when urgent (or semi-urgent) referral to secondary care may be indicated, e.g. in trauma, epistaxis,
quinsy (peritonsillar abscess), severe croup or stridor
. Understand when watchful waiting and the use of delayed prescriptions are indicated
. Demonstrate an evidence-based approach to antibiotic prescribing
. Demonstrate effective strategies for dealing with parental concerns regarding ENT conditions, such as recurrent
tonsillitis or otitis media with effusion, e.g. explain why antibiotics are not always indicated

a sore throat is not to acquire antibiotics, but rather to


Aetiology
..........................................................................................

........................................................... establish the cause of their symptoms, obtain pain relief,


and receive information regarding the course of the illness
Waldeyer’s ring is a ring of lymphoid tissues within the
(Butler, Rollnick, Pill, Maggs-Rapport, & Stott, 1998).
pharynx; it consists of the palatine tonsils (‘tonsils’), pha-
ryngeal tonsils (‘adenoids’), tubal tonsils (just posterior to
the eustachian tube opening), and lingual tonsils (on the
posterior aspect of the tongue). Tonsillitis refers to the
inflammation of the palatine tonsils and pharyngitis, an
The clinical approach
...........................................................
inflammation of the remainder of the pharynx. Multiple
The aim of the evaluation of patients with sore throat or
pathogens can contribute to tonsillitis but, in most (up to
acute pharyngitis is to exclude potentially dangerous
80%) cases, the causative agent is a virus. Table 1 pro-
causes, to identify any treatable causes, and to improve
vides a breakdown of the causes of tonsillitis. It is import-
symptoms. The evaluation includes a thorough history,
ant to remember that pathogens such as candida albicans
focused physical examination, and investigation in
can cause sore throats and be incorrectly diagnosed as selected patients.
tonsillitis.

As a GP, it is important to search for patient cues that may, History


in some cases, unearth a hidden agenda. It has been sug- The history provides important information to determine
gested that prescribing antibiotics inappropriately may whether the patient has a sore throat, or whether there is
over-medicalise what is usually a self-limiting condition a deeper pain in the throat or neck pain. Symptoms of
(Little et al., 1997). Contrary to popular belief, studies acute sore throat can vary between patients, and will occa-
suggest that the priority for patients attending with sionally depend on the cause. Distinguishing between

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life-threatening. In adults, although rare, acute epiglottitis
Table 1. Causative organisms of tonsillitis.
has similar symptoms along with a muffled or hoarse voice.
Bacterial Viral The incidence of epiglottitis has dramatically declined
since routine infant vaccination with Haemophilus influen-
Group A Streptococci Rhinovirus zae type b (Hib) vaccines began in 1991. These patients
should not be examined; rather they should be kept calm
Non-Group A Streptococci Influenza A and referred urgently to secondary care.

Otherwise, inspect the oral cavity, assessing for trismus


Neiserria gonorrhoea Adenovirus
(an inability to open the jaw) on mouth-opening. This
may indicate a peritonsillar abscess or a deep neck
Mycoplasma Pneumoniae Herpes simplex virus space infection. Although a whitish-yellow membrane
covering both tonsils may suggest glandular fever
Chlamydia Pneumoniae Epstein– Barr virus (infectious mononucleosis) caused by Epstein– Barr
Virus (EBV) infection and a generalised erythematous,
Corynebacterium Metapneumovirus swollen appearance with exudate is consistent with
Diphtheriae GABHS infection (Fig. 1). Viral and bacterial infections
Respiratory synctial are clinically indistinguishable. The presence of cough
virus and coryzal symptoms may suggest a viral aetiology.

Look for inflammation, ulcers, masses, exudate and


Parainfluenza
asymmetry within the pharynx. Persisting ulcers (longer
than 3 weeks) or masses should prompt an ENT sus-
pected cancer pathway referral. Assess the uvula, soft
a viral and bacterial cause is difficult in practice, as there is
palate, palatine tonsils and the pharynx. If the base of
often overlap between the symptoms and signs.
the uvula is deviated, along with soft palate oedema and
trismus, suspect a peritonsillar abscess.
Group A beta-haemolytic streptococcal (GABHS) infec-
tion usually presents with a sudden onset of sore throat,
Palpate the neck for cervical lymphadenopathy, making a
tonsillar exudate, fever, tender cervical lymphadenopathy
note of tender lymphadenopathy. This may suggest
and absence of a cough. Additional symptoms include
GABHS infection. Tender, symmetrical posterior cervical
halitosis, odynophagia, otalgia and upper airway
lymphadenopathy suggests EBV infection (Aronson &
obstructive signs, such as snoring or mouth-breathing.
Auwaerter, 2016), especially in teenagers or young adults
Viral tonsillopharyngitis, on the other hand, may have
with malaise, fatigue and a more persistent sore throat.
additional symptoms relating to a generalised viral
upper respiratory tract infection. This includes coryza,
Examine the ears, looking for an erythematous, bulging
nasal congestion, sinusitis, and hoarseness.
tympanic membrane suggestive of acute otitis media.
Restriction of neck movements should raise the suspicion
Children between the ages of 6 and 36 months present-
of a deep neck space infection, requiring an immediate
ing with a ‘barking cough’, hoarseness, stridor, and
referral to ENT specialists. Abdominal examination may
respiratory distress may be suffering from laryngotra-
reveal hepatosplenomegaly in patients with glandular
cheobronchitis (croup). Unilateral symptoms, such as
fever.
one-sided sore throat and ipsilateral otalgia, may suggest
spread of infection beyond the palatine tonsil capsule,
such as a peritonsillar abscess.

Examination
It is important to appreciate that patients presenting with
a sore throat may be seriously unwell and septic. As part
the examination, one should inspect the patient, obser-
ving for a ‘toxic’ appearance and signs of dehydration.
Vital signs and a thorough, systematic examination of the
ear, nose and throat (ENT) should guide the clinician
towards a diagnosis.

Drooling and an inability to take fluids orally should prompt


urgent referral to secondary care for intravenous
antibiotics. Drooling in children associated with fever, stri- Figure 1. Clinical photograph of acute bacterial tonsillitis
dor, dysphagia and an upright posture is highly suggestive showing enlarged, inflamed tonsils with exudate. The
of epiglottitis, which although uncommon, can be uvula is central.

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Table 2. Modified Centor scoring. Table 3. Pre-test probabilities of
Streptococcal infection in respect to the
Criterion Points Modified Centor Score.

Fever (greater than or equal 1 Modified Centor Score Probability of


to 38.3 C) Streptococcal
tonsillitis (%)
Absence of symptoms of a viral 1
upper respiratory infection
Less than or equal to 0 1–2.5
(conjunctivitis, rhinorrhoea,
or cough)
1 5–10
Tender cervical lymphadenopathy 1
2 11–17
Tonsillar erythema, oedema 1
3 28–35
Age
Greater than or equal to 51–53
3–14 years 1 4
Adapted from McIsaac et al. (2004).
15–44 years 0
symptomatic treatment is needed (Hawker et al.,
Greater than or equal to 45 years 1
2014). It is vital to quickly establish that a patient’s symp-
Adapted from McIsaac, Kellner, Aufricht, Vanjaka, & Low (2004).
toms are due to tonsillitis and not another, potentially
dangerous cause of sore throat (such as a retropharyn-
geal abscess or acute epiglottitis).
The combination of symptoms and epidemiologic features
has been used to develop clinical scores that can be used Throat cultures are not recommended for every patient in
to attempt to predict the likelihood that a sore throat is general practice (NICE, 2015a), and are unable to differ-
caused by GABHS infection (Breese, 1977; Centor, entiate between active infection and carriage (NICE,
Witherspoon, Dalton, Brody, & Link, 1981). The absence 2015a; Scottish Intercollegiate Guidelines Network,
of signs and symptoms of viral infections (e.g. coryza, 2010). When performed properly, the sensitivity of
conjunctivitis, cough, hoarseness, anterior stomatitis, dis- throat swabs is 90 to 95% for GABHS (Dingle, Abbott, &
crete ulcerative lesions or vesicles, diarrhoea) makes a Fang, 2014). Ideally when taking a throat swab, both tonsils
bacterial rather than a viral infection more likely. and posterior pharyngeal wall should be vigorously
swabbed without touching the tongue or buccal mucosa
The Centor score is a widely used and accepted clinical (Pichichero, 1995). Results take 48 hours to be reported.
prediction tool that has a reasonable negative predictive GABHS can be isolated from up to 30% of patients pre-
value in excluding GABHS. The scoring criteria are: senting with sore throats (Caserta & Flores, 2010), how-
Tonsillar exudate; tender anterior cervical lymphadenop- ever, values of asymptomatic carriage range between 6
athy; fever over 38 C; and absence of cough. The and 40% (Little & Williamson, 1996). Both cost and time
Centor score is most useful in identifying patients in limit the merits of throat swabs, but they may be useful in
whom neither microbiological tests nor antibiotic treat- patients that have failed treatment, or those patients in
ment are necessary. whom a decision has been made to delay antibiotics.

The Centor score was initially validated solely in adults, Rapid antigen detection testing (RADT) is not recom-
and thus not in children. It was therefore later modified mended as a routine investigation for acute sore throats
(also known as McIsaac score) to incorporate age, and by NICE (NICE, 2015a), however, NHS England has
was validated in about 600 adults and children (3–15 recently planned to roll out a ‘sore throat test and
years old) in a Canadian study (McIsaac, Kellner, treat’ service across pharmacies in the country over the
Aufricht, Vanjaka, & Low, 2004). To determine a patient’s next year. Patients will be able to visit pharmacies for
total score, points are assigned as detailed in Table 2. The RADT, and if positive, pharmacists will provide appropri-
predicted risk of GABHS infection depends on the total ate antibiotics without patients needing to see their GPs
modified Centor score as shown in Table 3. (Desmond, 2016). RADT has a specificity of greater than
95% and a varying sensitivity between 70 and 90% for
GABHS. Given its high specificity and limited sensitivity,
a positive RADT can be useful in establishing the diag-
Investigations nosis of GABHS tonsillitis, but a negative RADT does not
Patients with sore throat symptoms commonly visit their rule it out; in these cases throat culture swabs would be
GP, but in most cases the cause is viral and only beneficial (Pichichero, 1995).

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A full blood count may be helpful in patients with sus-
pected infectious mononucleosis, in immunocomprom- Differential diagnosis
...........................................................
ised patients, and in patients with signs or symptoms of
severe infection. Raised white cell count with lymphocy- Scarlet fever
tosis and atypical lymphocytes is suggestive of infectious Scarlet fever is caused by toxin-producing strains of
mononucleosis (IM). A positive monospot test in patients Streptococcus Pyogenes, a beta-haemolytic bacterium
with suspected IM is diagnostic of EBV infection, how- that is classified as a Group A Streptococcus. Scarlet
ever, due to low sensitivity, a negative monospot test fever is highly contagious, and is transmitted via drop-
does not rule out the diagnosis of IM. In these instances, lets. Outbreaks in schools and other institutions where
EBV-specific antibody testing may be carried out to con- there is close contact between individuals can occur.
firm the diagnosis. The incubation period is usually 2–3 days. The blanch-
ing rash usually appears on the second day of the ill-
Vaginal and cervical, or penile and rectal swabs should be ness, beginning on the chest and spreading to the
considered if there is a suspicion of a gonococcal throat abdomen and extremities. The rash is prominent in
infection, especially in sexually active adolescents and skin creases and has a sandpaper-like texture, due to
those engaging in oral-genital sex. A human immune the occlusion of sweat glands. The rash persists for
deficiency virus (HIV) viral load assay is indicated for several days, and later (up to 3 weeks) will result in
patients at risk of HIV infection who have persistent ton- desquamation. There is an exudative tonsillopharyngitis,
sillopharyngitis accompanied by severe constitutional and there may be small red haemorrhagic spots on the
symptoms. hard and soft palate. The face is flushed, with circu-
moral pallor and a red strawberry tongue

Red flags and serious Glandular fever (infectious mononucleosis)


diagnosis
...........................................................
EBV is the causative agent in patients typically present-
ing with a triad of sore throat, fever and lymphadenop-
athy. There is muscle ache and severe malaise out of
Box 1 summarises the red flag symptoms that should
proportion to the clinical picture (Caserta and Flores,
prompt an urgent referral to secondary care.
2010). Lymphocytosis may be apparent on full blood
count and a positive monospot test is diagnostic.
Box 1. Red flag symptoms. Ampicillin-based antibiotics should be avoided, as they
may precipitate a rash. There may be splenomegaly in
NICE recommends urgent referral for anyone with:
. An unexplained sore throat persistent for longer up to 50% of patients (Fisher & Boyce, 2005) due to
lymphocytic infiltration, rendering the organ susceptible
than 3–4 weeks (refer within 2 weeks) to rule out
to rupture, either spontaneously or traumatically. Splenic
malignancy
. Presence of red or white patches/ulceration/ rupture is rare (less than 0.5% of patients with IM), but
its consequences can be severe (Turner and Gard,
swelling of the oral/pharyngeal mucosa for
2008). Therefore, patients should be advised to avoid
more than 3 weeks
activities that increase intra-abdominal pressure and
. Pain on swallowing or dysphagia for more than
3 weeks contact sport for at least 4–6 weeks (Becker and
Smith 2014).
The following features may suggest another more
serious diagnosis:
. Stridor or respiratory difficulty (respiratory dis-
tress, drooling, systemically unwell, painful swal- HIV
lowing and muffled voice: suspect epiglottitis) HIV can cause ulcerative tonsillitis and pharyngitis with
. Suppurative complications (e.g. peri-tonsillar or fever. It occurs after an incubation period of 3–5 weeks
parapharyngeal abscess) as there is a risk of with symptoms of myalgia, arthralgia, lethargy, and
airway compromise in some people a non-itchy maculopapular rash.
. At risk of immunosuppression Lymphadenopathy develops a week later (Caserta &
. Suspected Kawasaki disease Flores, 2010).
. Diphtheria
. Signs of being severely unwell and with either the
cause being unknown or a rare cause is suspected, Herpes simplex virus pharyngitis
such as Stevens–Johnson syndrome (high fever, Herpes simplex virus (HSV) pharyngitis presents with
arthralgia, myalgia, extensive bullae in the mouth red, swollen tonsils that may have aphthous ulcers on
followed by erosion and a grey–white membrane) their surfaces. Herpetic gingival stomatitis, herpes labia-
Source: NICE (2015c). lis, and hypopharyngeal and epiglottic lesions may be
seen.

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with antibiotics improved symptoms 16 hours earlier
Complications
...........................................................
compared with those treated with supportive care only
(Spinks, Glasziou, & Del Mar, 2013). Symptom resolution
Peri-tonsillar abscess/quinsy was much more likely if antibiotic treatment was insti-
A spread of infection beyond the tonsil may lead to an gated within 2 days of symptom onset (Randolph,
abscess formation and collection of pus within the poten- Gerber, DeMeo, & Wright, 1985).
tial space between the tonsil and its containing fossa.
Clinical features include unilateral sore throat, trismus, Both suppurative and non-suppurative complications are
‘hot-potato’ voice, referred otalgia and odynophagia. uncommon, and clinical scoring does not predict the like-
Treatment is in the form of aspiration/incision and drain- lihood of acquiring these complications (Howie & Foggo,
age, and intravenous antibiotics. Rarely, these can pro- 1985; Little et al., 2013; Taylor & Howie, 1983). Reducing
gress to a parapharyngeal/retropharyngeal abscess, suppurative and non-suppurative complications requires
which can cause airway obstruction and mediastinal treating many patients with antibiotics (Spinks et al.,
infection. Suspicion of any extracapsular spread of infec- 2013). For example, the complication rate of acute otitis
tion should prompt an immediate referral to ENT. media (AOM) among those with sore throats is estimated
at 0.7%, implying a number needed to benefit (NNTB) of
Airway obstruction nearly 200 to prevent one case of AOM. In low-income
Airway obstruction is a rare complication and requires countries, complications are much more common, and
immediate referral to secondary care, where surgical therefore, the NNTB may be lower (Spinks et al., 2013).
intervention may be considered as an emergency. This In both instances, there is a balance between modest
may occur because of oedema of the soft palate and levels of symptom reduction and the risk of antimicrobial
tonsils following a deep neck space infection, peritonsillar resistance. In most cases, supportive management may
abscess or in rare circumstances, EBV infection. Common be all that is required in the form of adequate analgesia:
features include stridor, muffled voice, increased work of paracetamol and ibuprofen. Patients should also be
breathing and tachypnoea. advised to maintain adequate hydration and to rest.

Occasionally, antibiotics are recommended at first pres-


entation to treat: marked systemic upset, those with
Post-Streptococcal glomerulonephritis valvular heart disease or existing rheumatic heart disease,
Post-streptococcal glomerulonephritis is an inflammatory patients with scarlet fever and for complications of ton-
disorder of the kidneys that can manifest 1–2 weeks after sillitis. Patients with or without suppurative complications
a streptococcal throat infection. Common features of tonsillitis, and who are unable to swallow, will require
include dark urine, periorbital oedema, general malaise admission to secondary care for administration of paren-
and anorexia. teral antibiotics and fluids.

Antibiotics are recommended for patients at high risk of


Rheumatic fever complications, including patients who are immunocom-
Rheumatic fever is a rare, but serious, complication of an promised or have significant heart, lung, renal, liver or
untreated or partially treated streptococcal sore throat. neuromuscular disease. The high-risk group includes
Clinical features include polyarthritis affecting the larger patients with cystic fibrosis, and young children born
joints, and cardiac involvement which manifests as chest prematurely.
pain, shortness of breath and a new murmur; typically
mitral regurgitation. Valvular damage can persist long term. Antibiotics may also be considered in patients scoring
three or more on the modified Centor criteria. These
patients may be provided with a prescription for delayed
antibiotics, or with no antibiotics if no risk factors of
Treatment options
...........................................................
severe infection are present.

The medical treatment of sore throats does not necessarily The antibiotic of choice is Phenoxymethylpenicillin for 10
need to focus on the administration of antibiotics, as has days. A macrolide can be used as an alternative if an
historically been the case. Between 50 and 80% are due to allergy to penicillin exists. Ampicillin-based antibiotics
a viral cause, and therefore, the use of antibiotics should should be avoided in the treatment of sore throats, as
be discouraged to reduce the risk of antibiotic resistance. these may precipitate a widespread non-blanching macu-
lopapular rash in the presence of glandular fever.
In a 2013 meta-analysis, sore throat lasted between 2 and
7 days among children who received control, placebo, or NICE (NICE 2015b) suggests a delayed antibiotic pre-
over-the-counter treatment; the sore throat resolved by scription as an alternative prescribing strategy. In this
day 3 in approximately 60–70% of cases (Thompson case, patients can be offered:
et al., 2013). The duration of symptoms was similar in . Reassurance that antibiotics are not needed immedi-
children with and without GABS tonsillitis. Treatment ately, as they are likely to make little difference to

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...................................................................................................................................................................................................................................................
symptoms and may have side effects, such as diar- It is interesting to note that a cross-sectional observa-
rhoea, vomiting and rashes tional study of trends in emergency hospital admission
. Advice about using the delayed prescription if symp- for sore throats in the context of the number of tonsillec-
toms do not settle within the expected time frame, or tomies, found a 44% reduction in the overall tonsillec-
if a worsening occurs in the patient’s clinical status or tomy rate between 1991 and 2011. During the same
symptoms study period, the admission rate to hospital for tonsillitis
. Advice about seeking medical advice if there is a rose by 310%, for peritonsillar abscess by 31% and for
worsening in the clinical condition, despite using the retro/parapharyngeal abscess by 39% (Lau, Upile, Wilkie,
delayed prescription Leong, & Swift, 2014).

Ultimately, a clear explanation regarding the expected Tonsillectomy may be considered on a case-by-case basis
course of illness should be provided to the patient. It after careful consideration of the risks and benefits and a
should be emphasised that symptoms will resolve thorough discussion of the options with the patient. In
within 7 days, and that if there is worsening of symptoms cases where the diagnosis is uncertain, or there is a
or no improvement patients should re-present for review. doubt as to the clinical significance of the sore throats,
a period of active monitoring over a minimum of
The use of glucocorticoids has increased recently, but is 6 months can be beneficial, with patients recording epi-
controversial. The Infectious Disease Society of America sodes and symptoms in a ‘sore throat diary’.
advises against the use of steroids, however, in patients
with severe throat pain and/or inability to swallow, there Tonsillectomy is performed under a general anaesthetic,
may be a role (Shulman et al., 2012). and may involve an overnight stay in hospital. Recovery
takes up to 2 weeks and patients are advised to rest;
In cases of recurrent tonsillitis, referral to secondary care taking time off work/school. They will require regular
should be discussed for consideration of tonsillectomy. analgesia and should maintain a good oral intake, as
Although tonsillectomy has been shown to reduce the this has been shown to reduce recovery time and pre-
number of sore throats and improve general health, the vent infections.
procedure is not without risks. A study of 33 921 patients
undergoing adenotonsillar surgery in the UK between
2003 and 2004 reported a readmission rate of 3.9% and
Key points
a tonsillar haemorrhage rate of 3.5% (British Association of . Diagnosis of acute tonsillitis is clinical, and it can
Otorhinolaryngologists—Head and Neck Surgeons, 2005). be difficult to distinguish viral from bacterial
It is important to note that although tonsillectomy can pre- infections
vent recurrent episodes of tonsillitis, it will not affect recur- . GABHS accounts for up to 30% of the cases of
rent sore throats from other causes. Therefore, it is vital to tonsillitis in children and adolescents
confirm a diagnosis of recurrent tonsillitis and rule out sore . The modified Centor score is a useful validated
throats from other aetiologies prior to consideration of clinical prediction tool for diagnosing GABHS
surgical management. tonsillitis
. Complications of tonsillitis include peritonsillar and
The Scottish Intercollegiate Guidelines Network (SIGN) neck space abscesses, rheumatic fever and post-
published guidelines in 1999 on the management of sore streptococcal glomerulonephritis
throat and indications for tonsillectomy. These advise on . Most cases of tonsillitis are self-limiting and do not
the indications for tonsillectomy in both adults and chil- require antibiotics
dren and can be used to guide ENT referral in primary . Patients who fulfil the SIGN criteria, may be
care; they are listed in Box 2. referred to secondary care for consideration of
surgical management

References and further information


Box 2. SIGN criteria for surgical intervention
in secondary care. . Aronson, M. D., & Auwaerter, P. G. (2016).
Infectious mononucleosis in adults and adoles-
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College of General Practitioners, 33(257), 783–786

Mr Hussein Walijee
Speciality Trainee in ENT, Alder Hey Children’s NHS Foundation Trust, Liverpool
Email: hwalijee@gmail.com

Dr Chirag Patel
GP, Tanunda Medical Centre, South Australia

Mr Pranter Brahmabhatt
Speciality Trainee in ENT, Morriston Hospital, Swansea

Mr Madhankumar Krishnan
ENT Consultant, Alder Hey Children’s NHS Foundation Trust, Liverpool

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