Exudative Tonsillitis Research Articles

Tonsillectomy and adenotonsillectomy in Sudanese patients.

To highlight the indications for and complications of tonsillectomy or adenotonsillectomy operations in Sudanese patients and to find out whether any correlation can be deduced between routinely requested pre-operative investigations and the complications which may arise. A prospective study. Khartoum ENT Teaching Hospital, Khartoum, Sudan. One hundred and twenty patients, 55% females and 45% males, age range 3 to 50 years. Pre-operative investigations consisted of a complete blood count and bleeding and clotting times., ASO titres and urinalysis. Consisted of tonsillectomy or adenotonsillectomy performed on in-patients by one of the authors under general anaesthesia. High erythrocyte sedimentation rate (ESR) or ASO titres should not deter an indicated tonsillectomy operation which can still be carried out if meticulous haemostasis is observed. Three or more episodes of exudative tonsillitis per year and upper airway obstruction were the commonest indications for tonsillectomy or adenotonsillectomy accounting for 72.5% and 16.7% of the operations. Intra-operative bleeding occurred in 63 (52.5%) of the patients. Low figures of reactionary and secondary haemorrhages were seen. It is concluded that as bleeding, both intra- and post-operative is the main complication of tonsillectomy, its incidence can be reduced to minimal levels by careful selection of patients, in whom the operation is carried out under general anaesthesia with gentle handling of tissues and detention of the patients post-operatively for two to three days. We also found out that coagulation tests need not be routinely requested and reserved for patients with a history of bleeding tendencies.

Genital Ulcers as a Presenting Feature of Primary Epstein-Barr Virus Infection † 8

Genital ulcers (GU) have been rarely described in temporal association with acute Epstein-Barr Virus (EBV) infection, but a cause-and-effect relationship has not been established. A previously healthy 14-year-old girl with no history of sexual activity developed fever, sore throat, and low back pain; a day later, five painful ulcers appeared over her external genitalia. A hemogram was normal, herpes simplex virus (HSV) culture of the lesions was negative, and bacterial GU cultures grew normal flora. Her fever worsened(40.2°C) and the genital ulcers continued to enlarge. Examination on day 5 of GU showed deep, tender, hemorrhagic, coalesced ulcers involving both labia majora and minora, 2 mm aphthous ulcers on her buccal mucosa, no lymphadenopathy, and the hymen was estrogenized and without interruption. HSV cultures, ANA, VDRL, and HIV antibodies were negative. She was empirically treated with Augmentin®(2d) and then metronidazole (7d), as well as oral methylprednisolone (5d). On day 9 of GU, she was afebrile and the lesions were smaller and not hemorrhagic. A tentative diagnosis of Behcet syndrome was made. On day 15 of GU, she developed sore throat and dysphagia, but no fever. Examination revealed exudative tonsillitis and cervical lymphadenopathy; the ulcers were granulating and less tender. Her Monospot, EBV VCA IgG and IgM, and anti-EA (1:40) were positive; EBNA was negative. Whole blood, serum, and buffy coat obtained on day 16 of GU and the genital culture specimen obtained on day 5 (10 days before primary EBV infection was diagnosed) were assayed for EBV DNA using the polymerase chain reaction (PCR). The PCR assay was used to amplify a 177 bp region in the LMP-2A gene of EBV; the sensitivity of this assay was 8 EBV copies per 105 cells. All specimens were positive for EBV DNA. Conclusion: EBV DNA was found in genital ulcer specimens obtained 10 days before symptoms of EBV-related infectious mononucleosis were apparent. EBV should be considered as an etiologic agent of acute, non-venereal genital ulcers.

Pathogenesis of peritonsillar abscess.

The pathogenesis of peritonsillar abscess is described in textbooks as being a direct communication and progression of acute exudative tonsillitis. Little study has been done on the true etiology and pathogenesis of peritonsillar abscess. This paper focuses on the pathogenesis of peritonsillar abscess. A group of salivary glands (Weber's glands) proven to be located in the supratonsillar space have been shown to be implicated in the pathogenesis of peritonsillar abscess. A review of peritonsillar abscess has been undertaken, and evidence has been presented to support the premise that the true cause for peritonsillar abscess is not necessarily an extension of an acute exudative tonsillitis, but an abscess formation of Weber's salivary glands in the supratonsillar fossa.

Scintigraphic Demonstration of Jugular Obstruction in a Case of Lemierre Syndrome

A 19-year-old man had fever, sore throat, and general malaise for 4 days. Physical examination revealed exudative tonsillitis, a right submandibular lymph node, and swelling along the right sternocleidomastoid muscle. Initial results of a chest x-ray were normal. Blood cultures were positive for Fusobacterium necrophorum. Radionuclide venography with in vitro Tc-99m labeled red blood cells showed a delay in the right carotid-jugular complex blood flow. An ECHO Doppler examination demonstrated both a thickening of the wall and a partial thrombosis of the right internal jugular vein, suggesting thrombophlebitis. Lemierre syndrome (suppurative thrombophlebitis of the internal jugular vein secondary to an oropharyngeal infection) was diagnosed. The patient was given clindamycin, with good response.

Pharyngeal and tonsil infections caused by non-group A Streptococcus

Non-group A streptococci are members of the genus Streptococcus but do not share the notoriety of their cousin from group A. Most physicians, including otolaryngologists and head and neck surgeons, do not associate them with upper respiratory tract and head and neck infections. Some laboratories do not bother to report their presence on culture. At the University of California, Los Angeles they have been shown to cause (1) tonsillitis, painful tonsils lacking exudate and erythema (group C, one case; group F, one case), (2) acute nonexudative tonsillitis (group B, two cases; group C, one case; group F, one case), and (3) acute exudative tonsillitis (group C, one case). It should be remembered when there is a report of their presence that they are usually vulnerable to penicillin and its analogs. By judicious use of these drugs, morbidity can be diminished.

Association of Group C β-Hemolytic Streptococci With Endemic Pharyngitis Among College Students

Throat cultures were performed throughout 2 school years to determine whether non-group A beta-hemolytic streptococci (NGA BHS) could be isolated more frequently in 232 college students who had symptomatic pharyngitis than from 198 age-matched controls with noninfectious problems. Duplicate throat swabs were inoculated onto plates that contained sheep blood agar, one plate being incubated in a 5% CO2 atmosphere and the other in an anaerobic environment. The BHS were grouped using latex agglutination. Among the NGA BHS, only those from group C were isolated significantly more often among the patients compared with the controls (26% vs 11%). Quantitative colony counts of isolates of group C BHS were generally higher among patients than controls. Patients with group C BHS had fever, exudative tonsillitis, and anterior cervical adenopathy significantly more frequently than did patients who had throat cultures that were negative for group C BHS. Group C BHS were epidemiologically associated with endemic pharyngitis in this college student population.

Food-borne outbreak of group G streptococcal sore throat in an Israeli military base.

A food-borne outbreak of sore throat caused by Lancefield group G beta-haemolytic streptococci and involving 50 persons occurred in May 1983 in an Israeli military camp. All of the patients available for clinical examination had sore throat and difficulty in swallowing. Exudative tonsillitis occurred in 46% of the patients and the body temperature was above 37.5 degrees C in 81%. The pattern of attack was uniform over the base and 37 became ill during the night and morning of the 5 May. Thirty-two (84%) of the throat cultures taken from 37 patients grew group G beta-haemolytic streptococci. Eight of 29 contacts were positive for group G beta-haemolytic streptococci and 6 of the 28 foodhandlers examined had positive cultures of the same group. The organism was also isolated from one food sample. The epidemiological and laboratory investigations indicated that a food handler, a convalescent carrier of group G streptococci, might have been the source of infection. Assumptions on the potential of non-group A streptococci to cause epidemics are discussed.

Febrile Exudative Tonsillitis: Viral or Streptococcal?

A prospective 1-year study of acute febrile exudative tonsillitis in 110 children was carried out. Viral infection was associated with 42% of the cases, beta-hemolytic streptococci with 31% (12% group A), Mycoplasma pneumoniae with 5%, and unknown cause with 35%. More than one agent was implicated in 14% of the cases. Adenovirus was the viral agent most frequently (19%) recorded. Other viruses involved were Epstein-Barr virus, parainfluenza, influenza A, herpes simplex, and respiratory syncytial viruses. The responsible agent was found by rapid viral antigen detection in 20% of all cases and by rapid test for group A streptococcal antigen detection in 10%. Age was the most important factor in predicting the causative agent. Viral tonsillitis was most common in children younger than 3 years of age and group A beta-hemolytic streptococci tonsillitis in children 6 years of age or more. Clinical analysis of the illness, WBC count, and ESR did not reveal differences that could help in differentiating bacterial from viral tonsillitis. All patients were treated with a regimen of oral penicillin. Fever associated with group A beta-hemolytic streptococci tonsillitis responded to penicillin therapy significantly more rapidly than fever associated with viral infections. These observations demonstrate the prominent role of viruses in the etiology of febrile exudative tonsillitis, especially in young children, and reinforce the benefit of rapid tests before antibiotic therapy is started.

CHILDHOOD INFECTIOUS MONONUCLEOSIS NOT ASSOCIATED WITH EPSTEIN-BARR VIRUS

Non-Epstein-Barr Virus (EBV) induced infectious mononucleosis (IM) has not been adequately studied in children. In a prospective evaluation of 171 children with an illness characterized by clinical and hematologic findings for IM, 19 (11%) children had their episode unassociated with an acute EBV infection. The majority of children with non-EBV IM were <4 years old, 11 (58%), and males, 11 (58%). The spectrum of clinical manifestations in general were similar to that reported for EBV-IM in children except for a decreased rate of exudative tonsillitis in the non-EBV group, 5 (26%). Transient respiratory or hematologic complications developed in 2 children. Liver transaminases were elevated acutely and transiently in 6/10 children tested. Typical heterophil antibody responses were not detected. EBV testing indicated that 6 children had experienced this infection in the distant past; the infection in two others was of inconclusive onset. A suspected etiology was identified in 5 children: 3 had significant IgG antibody titer rises to cytomegalovirus (2 of these had the virus isolated from the urine) and 2 others had significant titer rises to Toxoplasma gondii. Children with non-EBV IM tended to be younger than that reported with EBV-IM. The non-EBV IM subgroup with suspected etiology appeared to be a major contributor to the low frequency of exudative tonsillitis. Reactivation of an EBV-carrier state provoked by the intervening etiologic agent was not documented as has been reported in adults. The majority of non-EBV IM episodes in children remains of unknown etiology.

The Diagnosis of Mononucleosis in the Office Laboratory

Infectious mononucleosis has been known for a long time to be a common infection in young adults. It also infects children. In particular, children under the age of 2 years may not express the illness clinically. Diagnostic criteria vary but in young adults usually include the symptoms of fever, exudative tonsillitis, and cervical lymphadenopathy. Usually, there is a relative and absolute lymphocytosis, with 10 to 20 per cent or greater atypical lymphocytes. Rapid slide tests are accurate and economical and support the diagnosis when positive. False-positive results are known to occur with several other important disease processes; therefore, the clinical presentation and laboratory results must be interpreted in their appropriate context. Quality control is essential even for the rapid slide tests, and experienced examiners are required to review blood smears. The morphology of atypical lymphocytes varies greatly. In addition, morphology interpretation can be hampered by problems in preparation of slides or the holding of blood samples awaiting slide preparation. EBV-specific serodiagnosis has significantly enhanced our ability to study further and differentiate heterophil-negative syndromes that share clinical features with infectious mononucleosis. Acute, past, chronic, and no EBV infection can now be differentiated. Further diagnostic tests for other etiologic agents are necessary when all EBV tests are negative and the clinical situation requires appropriate diagnosis.

C-reactive protein in the differentiation of adenoviral, Epstein-Barr viral and streptococcal tonsillitis in children.

Sixty-two children with febrile exudative tonsillitis were studied to explore whether quantitative measurements of serum C-reactive protein (CRP) are useful in differentiating viral from streptococcal tonsillitis. There were 23 cases of adenoviral tonsillitis, 21 of EB viral tonsillitis and 18 of streptococcal tonsillitis. Measurements of CRP, WBC counts and erythrocyte sedimentation rates (ESR) were not useful in distinguishing viral from streptococcal tonsillitis. Seventy-four percent of patients with adenoviral tonsillitis were under the age of 3 years and 71% of the patients with Epstein-Barr (EB) viral tonsillitis were under the age of 6 years whereas 72% of the patients with streptococcal tonsillitis were over the age of 6 years. Age was clearly the most important factor in distinguishing between viral and bacterial tonsillitis in children.

Concurrent outbreaks of influenza A and influenza B.

During the winter of 1982 concurrent outbreaks of influenza A and influenza B occurred. The epidemiology and clinical features of 151 cases referred during this time are described, and patients are discussed according to age and presenting clinical syndrome: croup was the commonest presentation in young children, a typical influenza syndrome predominated in young adults, while older patients were more likely to have lower respiratory tract infection. There was no significant difference between the clinical features of influenza A and influenza B. Unusual clinical features include rash, exudative tonsillitis and the need for myringotomy during the course of influenza.

Rapid diagnosis of adenoviral tonsillitis: A prospective clinical study

Adenovirus antigen was detected by radioimmunoassay in the nasopharyngeal specimens of 30 of 74 children with febrile exudative tonsillitis. In the other 44 children, the cause of tonsillitis was identified in 16 (beta-hemolytic streptococci or Epstein-Barr, parainfluenza, or herpes simplex viruses). The clinical picture of adenoviral tonsillitis was difficult to differentiate from that of streptococcal disease; 20 of the patients had originally been given antibiotics. In 68% of patients without complications, the serum concentration of C-reactive protein was less than 20 mg/L, suggesting a viral disease. No other hematologic test was found helpful in identifying the adenoviral tonsillitis. The rapid detection of adenovirus antigen permitted withdrawal of unnecessary and ineffective antibiotic treatment in most patients.

Infectious Mononucleosis and Leukemia

To the Editor.— Regarding the association of infectious mononucleosis and acute leukemia (1981;246:1783), readers might be interested in this case report of a girl in whom a bone marrow examination was done during the onset of a severe case of infectious mononucleosis one year before acute myeloblastic leukemia developed. Report of a Case.— A 14-year-old girl was seen for an acute onset of a febrile illness associated with severe fatigue. On examination, she was noted to be extremely pale. She had exudative tonsillitis, generalized glandular enlargement, and a spleen that was palpable 3 cm below the costal margin. She experienced severe epistaxis that day and had right periorbital ecchymosis. The hemoglobin level was 10 g/dL. The hemoglobin level determined two weeks previously during a routine annual examination was 13 g/dL. A bone marrow examination was performed and revealed typical findings of infectious mononucleosis. The patient had an uneventful recovery during

Association of Epstein-Barr virus with acute exudative tonsillitis.

This report is concerned with acute exudative tonsillitis as a pathologic response to the Epstein-Barr virus (EBV). The concept of a bacterial-viral etiology etiology for tonsillitis has been suggested, and previous studies implicate EBV as a major pathogen in exudative tonsillitis. A prospective study of 16 patients with this diagnosis was conducted. EBV serologic data plus viral and bacterial throat cultures were compiled and evaluated. EBV as a casual agent alone or concurrent with other organisms was seen in 56% (9) of the patients under study. EBV activation was associated with infection by other organisms in 19% (3) of the cases. The overall total incidence of EBV in association with severe acute exudative tonsillitis was 75% (12). The data further documents EBV as a significant causal or associative agent in acute exudative tonsillitis.

Peritonsillar abscesses in children.

A follow-up retrospective study was performed on 41 children who presented with peritonsillar abscesses from 1970-1980. The ages ranged from 3 to 16 years, with the mean age of 10 years. There were 26 females and 15 males. The abscesses were predominantly left-sided (28 vs. 13 right-sided) and the mean duration of symptoms was 3 days. Of the patients, 39% had been treated with antibiotics prior to the abscess development. Only 15% of the patients had a documented past history of exudative tonsillitis. Of the 41, 1 patient was lost to follow-up, and 11 underwent tonsillectomy for the abscess. Thus, 29 patients were reviewed who received no surgical therapy for their peritonsillar abscess other than incision and drainage. These patients were contacted for an interval history with a period of follow-up ranging from 6 months to 10 years. Only 2 of the 29 patients (7%) had recurrent abscesses. Two other patients (7%) had further recurrent bouts of exudative tonsillitis but not abscesses. These 4 children were in an initial group of 6 who had a prior history of documented tonsillitis. The incidence of recurrent peritonsillar abscesses reported in the literature has ranged from 7.6 to 16% in series which were comprised mainly of adults. The low incidence of recurrent abscesses (7%) in this series would indicate a need to reevaluate the indication for tonsillectomy for peritonsillar abscess in the pediatric age group. The authors recommend that tonsillectomy be performed in those children who present with a previous history of documented tonsillitis or suffer a complication at the time of the first abscess (neck abscess or airway compromise).

A prospective clinical study of the mononucleosis syndrome in a developing country.

A prospective aetiologic analysis made of 70 children and adults with the clinical and haematologic features of infectious mononucleosis (IM) in Sao Paulo, Brazil, revealed 65.7% due to EBV (31 heterophile antibody positive (HA+), 15 HA negative (HA-) cases), 8.6% due to T. gondii and 4.3% due to CMV. One case was related to viral hepatitis and one to drug hypersensitivity. The other 18.6% were of unknown cause. In the 46 IM cases positive tests were found for EBV/IgM in 93.5%, for heterophile by the absorbed horse Rbc test in 64.2% and by sheep Rbc in 37%. The immune-adherence haemagglutination test was slightly more sensitive than the horse Rbc test in 39 IM sera tested. In 41 EBV/IgM positive sera, EBV/IgA was present in 17/25 containing heterophile antibody and in 2/16 lacking heterophile antibody; anti-EA was present in 85%. The average age of HA+ IM cases was 13.2 years and of HA- cases 4.7 years. Three HA+ and 5 HA- IM cases occurred in the 0-2 year old age group. Few clinical features differentiated between aetiological agents. Exudative tonsillitis was the most helpful one and occurred in 67.7% of HA+ IM cases, 26.7% of HA- cases, in 1 of 3 CMV cases, and not at all in 6 T. gondii infections.

EBV antigens in lymphocytes of patients with exudative tonsillitis, infectious mononucleosis and Hodgkin's disease.

A protocol utilizing isokinetic gradients to isolate human lymphocytes is combined with another that purifies the C3 receptor-bearing B lymphocyte subpopulation, thus enriching the EB virus genome-carrying population. Also, rabbit antisera were prepared to the Epstein-Bar virus nuclear antigen (EBNA) and the early antigen (EA) and utilized in an indirect immunofluorescence test (IIT) to detect these antigens in human lymphocytes isolated from various disease states. Using these methods we demonstrated excellent correlation between standard methods previously employed to detect EB virus-coded antigens and our IIT employing xenogenic antisera. Such tests were done on lymphoblastoid cell lines as well as lymphocytes isolated directly from patients with EB virus lymphoproliferative diseases. Human palatine tonsil-derived lymphocytes from children with exudative tonsillitis and peripheral blood lymphocytes of infectious mononucleosis contained only EBNA in C3 receptor-bearing B lymphocytes. However, patients with lymphoproliferative disorders, including Hodgkin's disease, harbored in their spleens and lymph nodes lymphocytes producing both EBNA and EA.

Acute Pharyngotonsillitis Caused by Herpesvirus Type 2

HERPES simplex virus (HSV) type 1 is now recognized as a common nonbacterial cause of acute pharyngitis in young adults.1Herpes simplex virus type 2 is most often associated with urogenital infections of men or women and is generally transmitted venereally.4Acute exudative pharyngitis and tonsillitis developed in a bisexual man following oral-genital sex with male and female partners. Herpes simplex virus type 2 was recovered from the pharynx and identified in a biopsy specimen of tonsillar tissue. Report of a Case A 25-year-old bisexual man had fever, chills, odynophagia, and inability to swallow oral secretions for four days. He had received one dose of intramuscularly administered penicillin and had taken ampicillin orally for three days without relief. He had engaged in oral-genital sex with male and female partners ten days previously. He denied previous oral or genital herpes but had been treated for syphilis in the past.

Epstein-Barr Virus Genome Carrying Lymphocyte Subpopulations of Human Palatine Tonsils

Introduction. The human palatine tonsil, a major lymphoid organ of the oropharynx, has Received the focus of attention in relation to EBV localization in the head and neck. Serological studies of Tischendorf (1) first showed a relationship between EBV and heterophil-negative exudative tonsillitis. Later, our laboratory (2) supported and expanded these findings by reporting significant IgM-specific antibody titer changes for EBV occurring in patients with the same disease. Subsequently, Werner (3) experimentally inoculated gibbons intratonsillary with EBV and all animals contracted exudative tonsillitis and sero-converted following incubation. Evidence of the virus, Epstein-Barr nuclear antigen (EBNA), was then found by Veltri et al. (4) in the tonsil lymphocytes of patients with exudative tonsillitis, along with positive serology to EBV, early antigen (EA), and/or virus capsid antigen (VCA). The purpose of this investigation was to confirm the existence of a defined patient sample harboring latent EBV and...