CASE STUDY: ACUTE EXUDATIVE TONSILLITIS
This is a case of a 17-year old male who presented with an acute onset of sore throat, painful swallowing, hoarseness, bilateral ear pain, headache, body malaise, and fever. The physical findings of enlarged hyperemic tonsils with yellowish exudate along with presenting symptoms is suggestive of bacterial etiology. An initial diagnosis of Acute Exudative Tonsillitis was made with differential diagnoses of Acute Mononucleosis, Peritonsillar Abscess and Gonococcal Pharyngitis. Diagnotic tests to confirm initial diagnosis and to rule out the differential diagnoses include Rapid Antigen Detection Test, throat culture for Group A Beta Hemolytic Streptococcus and Neisseria Gonorrhea, Monospot test. Once diagnosis is confirmed and GABHS is established as the causative agent, empiric antibiotic treatment should be started immediately. Penicillin V is the first line of antibiotic but Amoxicillin is most often prescribed. Antibiotic treatment should be completed for 10 days. This ensures relative protection from complications such as rheumatic fever. In patients with Penicillin or Amoxicillin allergy, Macrolide is an alternative choice with the advantage of shorter antibiotic treatment, typically 3 – 5 days, which translates to better patient compliance and a greater chance of completion of the full course of antibiotic therapy. Supportive measures include bed rest, oral hydration, analgesics and steroids. Patient should be educated about personal hygiene with emphasis on hand washing, avoid touching mouth, nose, or eyes, keeping distance from infected individuals and safe sex practice.
CASE STUDY: ACUTE EXUDATIVE TONSILLITIS
PATIENT INFORMATION: S.J. is a 17-year old Caucasian male. CHIEF COMPLAINT: Sore throat for 2 days
HISTORY OF PRESENT ILLNESS: S.J. was brought in by his mother because of sore throat which occurred two days prior to consult. Mother shared that her son was exposed to a classmate with similar symptoms one day prior to the appearance of his symptoms. S.J. describes his sore throat as constant, burning in nature, 9/10 on the pain scale and worsens with eating and swallowing especially non liquid food. This was also associated with hoarseness, headache, body weakness and high fever (maximum reading of 101.9 F) which breaks off with intake of Tylenol 500 mg every 4 hours as needed. Patient also states that he would experience some relief of sore throat when drinking warm lemon juice. Due to his symptoms progressively getting worse, mother decided to bring him for medical consultation.
ALLERGIES: No known food or drug allergies.
PAST MEDICAL HISTORY: Patient denies any previous hospitalizations and presence of other co morbid medical conditions. Immunization status up to date.
PAST SURGICAL HISTORY: Patients denies any previous surgeries. FAMILY HISTORY: (-) Heart Disease, Kidney pathology, Rheumatic Fever
SOCIAL HISTORY: High school student attending public education, resides with parents and 2 other younger siblings. Denies smoking, alcohol intake, and tobacco or illicit drug use.
SEXUAL HISTORY: Sexually active, in a monogamous relationship with current partner.
REVIEW OF SYSTEMS:
Constitutional: No chills, weight changes, fatigue, weakness, night sweats.
Skin: No rash, discoloration, itching, pruritus, lumps/bumps, nail, or hair changes. Head: (+) headache, no dizziness, lightheadedness, or vertigo.
Eyes: No changes in vision, eye pain, tearing, eye discharge.
Ears: (+) ear pain bilaterally worse with swallowing, no aural discharge, ear fullness, tinnitus, or hearing loss.
Nose/Sinuses: No congestion, nasal discharge, epistaxis, sinus pain, sneezing, Oral: No sores, dental cavities, gum lesions or gingivitis, gum bleeding.
Throat/Neck: (+) sore throat, hoarseness, dysphagia, no neck pain, no neck swelling. Cardiovascular: No chest discomfort, palpitations, orthopnea, shortness of breath.
Respiratory: No dyspnea, cough, hemoptysis, shortness of breath, wheeze. Gastrointestinal: Unable to eat well due to painful swallowing, no abdominal pain,
heartburn, nausea, vomiting, changes in bowel habits or blood in stools.
Genitourinary: No dysuria, hematuria, urinary frequency, incontinence, genital discharge.
Musculoskeletal: No leg pain, cramps, joint pain, joint stiffness, swelling, weakness. Neurological: No headaches, seizures, tremors, numbness, tingling.
Endocrine: No polyphagia, polydipsia, polyuria, denies intolerance to heat or cold. Hematological: No easy bruising, anemia.
Psychiatric: No anxiety, feeling of sadness, mood swings, insomnia.
PHYSICAL EXAMINATION:
General Survey: Patient is awake, alert, oriented, not in acute respiratory distress. VS: BP:110/78 mmHg PR: 100/min RR: 18/min Temp:101F (oral) O2 sat: 98% Hgt: 5’7” Wgt:150 lbs BMI: 23.49
Skin: pink, warm, moist, intact, no rashes, no atypical pigmentation.
Head: normocephalic, even hair distribution, no scalp lesions or bald spots, no scalp tenderness or palpable mass.
Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation, (+) red orange reflex bilaterally, fundoscopic findings shows no papilledema, no retinal hemorrhages, blood vessels appear normal with sharply demarcated optic disc.
Ears: normal pinna, no lesions, no tragal tenderness, otoscopy showed non erythematous ear canal, minimal cerumen, no aural discharge, tympanic membrane pearly gray, good cone of light, no bulging or retraction, bilaterally.
Nose/Sinus: nasal septum midline, nostrils patent bilaterally, no nasal discharge, pink nasal mucosa, no bogginess noted, no tenderness over frontal and maxillary sinuses.
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Oral/Throat: pink moist oral mucosa, no oral lesion, good dentition, no dental caries, no halitosis, no gum lesions, swelling or bleeding. Pink pharyngeal wall, cherry red swollen tonsils (+3) with yellowish exudates bilaterally.
Neck: supple, no tenderness, no stiffness, carotid pulse with normal upstroke, no bruit appreciated. Palpable mobile, enlarged tender superficial cervical lymph nodes bilaterally, trachea midline, thyroid normal size and consistency, no palpable mass.
Cardiac: normal rate regular rhythm, no heaves, no thrills, S1 and S2 sounds normal, PMI best appreciated on the 5th ICS-MCL, no murmur.
Lungs: respiratory effort even and unlabored, no intercostal or supraclavicular retractions, symmetrical chest expansion, equal tactile fremitus bilaterally, resonant on percussion, clear breath sounds on all lung fields, no wheeze, no ronchi, no rales.
Abdomen: flat, no skin discoloration, no visible lesion, flat umbilicus, normoactive bowel sounds, soft, no tenderness on palpation, liver span 7 cm, spleen non palpable, no mass
Genitalia: Tanner stage V, normal looking circumcised penis, no penile discharge, testes bilaterally descended, non tender, no swelling, no palpable scrotal or testicular mass.
Extremities: no rashes, no abnormal pigmentation, no edema, no swelling, no deformity, pulse full and equal on all extremities, good range of motion, muscle strength 5/5 on all extremities. DTRs (+2) bilaterally.
Neurologic: alert, oriented to time, and place, responds appropriately to questions, CN I – XII intact, good coordination and balance, no gross or fine motor deficits.
ASSESSMENT:
PRIMARY DIAGNOSIS: Acute Exudative Tonsillitis
The patient is this case study presented with an acute onset of sore throat, fever, odynophagia (painful swallowing), hoarseness, and otalgia (ear pain) coupled with the physical findings of erythematous and edematous enlargement of the tonsils bilaterally and presence of anterior cervical lymphadenitis which strongly suggest a diagnosis of Acute Tonsillitis. The presence of yellowish exudates is highly suggestive of bacteria as the etiologic agent of the disease thus descriptive of an exudative type of tonsillitis. The patient’s
course of illness patterns that of the classic presentation of Acute Tonsillitis. This is further strengthened by a positive history of exposure to an individual who presented with the same symptoms.
Tonsillitis is defined as inflammation of the tonsils. Tonsils are part of the lymphoid system of the body and has a significant role in fighting infections. They appear as pink fleshy structures on each side of the pharynx and are equal in size. Tonsils typically have pits called crypts running through its mucosa which are colonized by different types of microorganisms. Microscopically, tonsils also have lymph nodules which are made up of immune cells particularly B cells, T cells, and macrophages. Tonsils are part of the Waldeyer’s ring which consists of the palatine, lingual, and tubal tonsils together with the adenoids. Until the age of 6, tonsils are expected to be hyperplastic after that they start to regress in size and shrink by 12 years of age. When a patient has tonsillitis, the palatine tonsils are mainly involved. Palatine tonsils are highly vascularized which is why bleeding is one of the most common post operative complication following tonsillectomy.
Tonsillar invasion by either viral or bacteria result to infection. Insults caused by microorganism leads inflammatory responses. The mode of transmission is droplet infection by either close or direct contact (coughing, sneezing, kissing, touching contaminated object). Common viruses causing tonsillitis include Ebstein Barr virus, Adenovirus, Rhinovirus, Coronavirus, Influenza and Parainfluenza viruses while the main bacterial etiologic agent involved is Group A Beta-hemolytic Streptococcus (GABHS), however Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been identified as
possible causes. Viral etiology is more common than bacterial. It is therefore crucial for the health care provider to identify the difference in order to provide appropriate medical management. The signs and symptoms of Acute Exudative Tonsillitis such as sorethroat, fever, pain, tonsillar erythema and edema, lymphadenitis are due to the release of inflammatory cytokines by the pathogen invasion. Inflammatory cytokines cause increased vascular permeability and leakage of protein and fluid into the surrounding tissues resulting to tonsillar edema. In addition, cellular injury and hemolysis causing erythema, release of pyrogens resulting to fever, and increase in lymph drainage into regional lymph nodes leading to cervical lymphadenitis, simultaneously occur. The findings of yellowish exudates can be explained by the cytokine mediated leucocyte activation, infiltration, and opsonization of the pathogen at the tonsillar site resulting to accumulation of cellular debris and byproducts of the inflammatory response (Marchak, 2008). The presence of otalgia (ear pain) in a patient with Acute Tonsillitis but with no evidence of ear infection is often considered a referred pain due to the involvement of the Jacobson’s nerve, a derivative of the glossopharyngeal nerve (CN IX). Cranial nerve IX provides sensory innervation to the oropharynx, middle ear, eustachian tube, posterior third of the tongue, the carotid body and sinus. According to a study conducted by Z. Abd-Alkader Taboo and M. Buraa on the etiology of otalgia, referred otalgia may be experienced when there is presence of inflammatory lesions of the palatine tonsils, nasopharynx, soft palate or the posterior third of the tongue due to the involvement of the sensory arm of the glossopharyngeal nerve (Taboo and Buraa, 2013).
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