Pseudomembranous necrotic pharyngotonsillitis: a microbiologic criminal conspiracy

Abstract

Within a few months, two young people were hospitalized in the infectious diseases department of Bordeaux University Hospital, France, for severe infectious mononucleosis tonsillitis. Both had fever, dysphonia, hypersialorrhea, halitosis, aphagia and activated circulating lymphocytes. Pharyngeal examination revealed a bilateral pseudomembranous and necrotic tonsillitis. Both had a good oral health and did not smoke nor reported alcohol use disorder. The diagnosis of infectious mononucleosis was confirmed by Epstein-Barr Virus serology and plasmatic PCR in both cases. The first patient was a 19-year-old man, he had received oral corticosteroids which had worsened the symptoms. The second patient was a 21-year-old woman. The rapid chromatographic immunoassay for qualitative detection of group A streptococcal antigen was negative for both patients. Necrotic pseudomembranes were swabbed, smeared on a slide before Gram staining which revealed in both cases a fusospirillar association evocative of Plaut-Vincent’s tonsillitis considered to be caused by Treponema vincentii and Fusobacterium nucleatum. Bacterial culture of necrotic pseudomembranes was negative in both cases. Both were treated by metronidazole in order to prevent the classically described amoxicillin-induced rash in infectious mononucleosis. Their symptoms rapidly improved under antibiotic therapy until full recovery. The association between infectious mononucleosis and Plaut-Vincent’s tonsillitis has seldomly been described in the literature ( 1 Pino Rivero V. González Palomino A. Pantoja Hernández C.G. Trinidad Ramos G. Marcos García M. Rejas Ugena E. et al. [Plaut-Vincent’s acute necrotizing ulcerative fusospirillum tonsillitis associated to infectious mononucleosis]. An Otorrinolaringol Ibero-Am. 2006; 33: 219-224 Google Scholar ), however Plaut-Vincent’s tonsillitis might be underdiagnosed since Gram staining on tonsil swabs is rarely performed in pharyngotonsillitis. Plaut-Vincent’s tonsillitis has been described for the first time at the end of the 19th century, first by Plaut in 1894 then by Vincent in 1898 ( 2 Harrell V. The present status of Plaut-Vincent's infection. Arch Otolaryngol. 1931 1; 14: 1-8 Crossref Google Scholar ) (Fig. 1).