Acute Exudative TonsillitisMAY 19, 2009 4 COMMENTS Tonsillitis is a common illness that requires a careful clinical assessment in order to identify underlying etiology and to avoid morbidity and mortality. Case Presentation A previously healthy 35-year-old man with history of appendectomy, bilateral inguinal hernia repair, lumbar laminectomy, chronic low back pain, opiod dependence, and recurrent tonsillitis presented with 2-day history of headache, high fever and chills, painful deglutition, inability to swallow solids, and lower abdominal pain in May this year. He denied rash, nasal discharge, cough, muscle aches, joint pains, nausea, vomiting, diarrhea, and urinary symptoms. Assessment On examination he was tall, well nourished, moderately ill, and tachycardic due to fever of 38.3°C. Physical examination revealed orthopnea, bilateral tender jugulodigastric lymphadenopathy, trismus, odynophagia, pooling of saliva, pharyngeal congestion, erythematous uvula, soft palate erythema, and bilaterally enlarged tonsils covered with white exudates (Figure, A and B). Routine laboratory tests showed polymorphonuclear leukocytosis and negative monospot test. Soft tissue radiograph and magnetic resonance imaging study of the neck revealed prominent tonsillar pillars and tonsillar enlargement (peritonsillitis). Tonsillar exudate culture confirmed beta-hemolytic group A streptococcal tonsillitis. Differential diagnosis includes beta-hemolytic streptococci (Lancefield groups B, C, and G), Epstein-Barr virus, adenovirus, Fusobacteria, Arcanobacterium hemolyticum, Corynebacterium diphtheriae, C. ulcerans, Francisella tularensis, Yersinia entercolitica, and Neisseria gonorrhea. Streptococcal exudative lesions are seen as milk white or gray scum (follicles), which can be removed without bleeding. Such follicular exudates coalesce if untreated and mimic a C. the most common cause of pseudomembranous tonsillitis. erythematous or exudative tonsillitis. Adenovirus tonsillitis. peritonsillar and retropharyngeal abscess. sour-sweet yeasty odor. accentuated on flexor creases—“Pastia’s lines”). red tongue with enlargement of the papillae (“strawberry tongue”). odynophagia. beefy red swollen uvula. tonsillar pseudomembrane formation due to necrosis of superficial layer of tonsil. leaving the underlying surface bleeding (pseudomembrane). gastroenteritis. and neurologic dysfunction due to diphtheria toxin. common in winter and early spring. tender anterior cervical adenitis. influenza-like illness. Infectious mononucleosis usually causes fever. sharply demarcated pseudomembrane consisting of inflammatory cells.(3) Streptococcal tonsillitis. and pharyngoconjunctival fever. red cells. causing suppurative thrombophlebitis and metastasis (Lemierre syndrome). palatal petechiae. with whitish-yellow tonsillar exudates with gingivostomatitis. septicemia. and removal would result in bleeding. and necrotic tonsillar epithelial layer in a network of fibrin adherent to underlying tissue. neck pain. ulcerans produce gray-white. follicular. causes tonsillitis with or without infectious mononucleosis. circumoral pallor.(1) The tonsils can be severely enlarged and are covered with an extensive necrotic.“pseudomembrane. scarlet fever rash (due to erythrogenic toxin causing punctate red macules in proximal extremities. peritonsilitis (peritonsillar cellulitis). Oropharyngeal infection may spread to underlying carotid sheath. diphtheria pseudomemrane can involve the uvula and soft palate. . The exudative lesions are accompanied by vesicles and ulcerations. pseudomembranous exudate. causes coryza. otalgia. ulceration. acute rheumatic fever. headache. keratoconjunctivitis. nausea. periorbital and upper eyelid edema (Hoagland’s sign). Anaerobic tonsillitis (Vincent angina) due to Fusobacterium necrophorum presents as gingivostomatitis. soft palatal petechiae (“doughnut” lesions). bilateral posterior cervical lymphadenopathy. seen usually in public swimming pools and in military recruits. Epstein-Barr virus. Corynebacterium diphtheria. mediastinitis. is seen in sexually active patients. pseudodephtheria. erythematous. abdominal pain. Other features are anterior and submandibular cervical lymphadenopathy (bull’s neck). is manifested as acute onset of fever. grayish-white membranous exudate.(2) Unlike EpsteinBarr virus. Arcanobacterium haemolyticum tonsillitis in college students is often accompanied by scarlatiniform rash. and fetid odor. toxic shock syndrome. cardiorespiratory insufficiency.” Others produce a gray-white tightly adherent layer that can be removed. Diagnosis Beta hemolytic Group A streptococci is the most common cause of acute tonsillitis. Tonsillitis with tender anterior cervical lymphadenitis in a person with a recent history of exposure to streptococcal tonsillitis is highly suggestive of streptococcal group A etiology. sore throat. Herpes simplex tonsillitis often follows herpes labialis and gingivostomatitis. Gonococcal tonsillitis. and Gianotti-Crosti syndrome. and C. hepatosplenomegaly. ampicillin rash. flushed cheeks. sore throat. vomiting. pneumonia. 5) Hence. 8) Acute exudative tonsillitis involves a number of causative pathogens and a wide spectrum of severity. lack of protective alpha-hemolytic streptococci (co-pathogens). and loss of penicillin-binding protein expression (“Eagle effect”). presence of tissue beta-lactamase produced by organisms like Staphylococcus aureus. Clinical features include muffled voice (“hot potato voice”). or in the presence of comorbidities. ultrasound.(7. nasopharyngeal stenosis. Patel. or 3 episodes per year for 3 consecutive years. MD. streptococcus and Epstein-Barr virus. or cephalosporin with or without clindamycin may be used. Peritonsillar abscess is often confused with severe exudative tonsillitis. Patel. In tonsillitis. trismus (inter-incisor distance is usually Treatment The primary antibiotic treatment for acute streptococcal tonsillitis consists of amoxicillin for 10 days to prevent recurrence. pain.poststreptococcal glomerulonephritis. Devesh N. is characterized by accumulation of pus between the tonsil and its capsule. if no response is evident within 48 hours of penicillin therapy. even though streptococcus is sensitive to penicillin. Our patient with streptococcal tonsillitis was successfully treated with piperacillin/tazobactam and hydrocortisone. the most common complication of acute tonsillitis. In case of peritonsillar abscess or enlarged tonsils obstructing airway.(6) Quinsy tonsillectomy is usually avoided because of anesthesia risk.(4. adequate clinical improvement might not be seen. bleeding. rheumatic fever. then Ampicillin/Sulbactum or Amoxicillin-Clavulanate. computed tomography scan or. macrolide or clindamycin may be tried. and not the pillars. MD References . or cardiac valvular disease. – Nilesh N. use of steroid is beneficial. In penicillinallergic patients. there was recent antibiotic exposure. and PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections). A meticulous clinical examination would differentiate between the 2 most common causes. Sometimes. This is due to paradoxically reduced bactericidal activities at high drug concentrations. Amoxicillin-Clavulanate. there are high penicillin failure rates in the community. or macrolide plus metronidazole. 5 episodes per year for 2 consecutive years. and glomerulonephritis. Treatment for peritonsillar abscess is drainage of abscess through needle or incision. are enlarged. preferably. magnetic resonance imaging of the neck. Peritonsillar abscess. Recurrent streptococcal tonsillitis may be treated with clindamycin. tonsils. Tonsillectomy is indicated in patients with recurrent tonsillitis and failure of medical treatment involving 6-7 episodes of acute tonsillitis in 1 year. It is necessary to distinguish between tonsillitis and peritonsillar abscess by clinical examination. amoxicillin plus rifampin. and even death. overwhelming number of organisms. 13(4):389–399. Bishai BR. Hirschmann J. Eagle H. Ozbek C.1. Am Fam Physician. New York: McGraw-Hill. 7. Use of corticosteroids in treating infectious diseases. Arch Intern Med. 2002. 2004. J Laryngol Otol. 2008.168(10):1034–1046. Does this patient have strep throat?. MEDLINE | CrossRef 4. http://amjmed.118(6):439–442. MEDLINE 8. 2008. JAMA. Yoda K. Aygenc E. 2007. Abstract | FullText PDF (1068 KB) | MEDLINE | CrossRef 5. Experimental approach to the problem of treatment failure with penicillin (I.284(22):2912– 2918. Steyer TE.126(2):185–193. Diphtheria and other infections caused by Corynebacteria and related species. In: Kasper DL editors.71(10):1501–1508.p. Int J Pediatr Otorhinolaryngol. Kurata T. Smith MA. 890–895. MEDLINE 2.. Abstract | Full Text | Full-Text PDF (152 KB) | CrossRef 6. Peritonsillar abscess: diagnosis and treatment. Am J Med. Oropharyngotonsillitis associated with nonprimary Epstein-Barr virus infection. 2000. CrossRef Figure (A) Streptococcal tonsillitis: white exudate on swollen tonsil. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Harrison’s Principles of Internal Medicine. Use of steroids in the treatment of peritonsillar abscess. Sata T. 2000.org/acute-exudative-tonsillitis/ . This article originally appeared in the January 2009 issue of The American Journal of Medicine. Murphy JR. Ebell MH.65(1):93–96. Arch Otolaryngol Head Neck Surg. Figure(B) Streptococcal tonsillitis: the classic finding is the presence of white follicular exudates. Aramaki H. McGee S. 1952. 3. Brook I. Soft palatal erythema also is present. Group A streptococcal infection in mice). 17th edn.