Acute Tonsilitis

Haemolytic streptococcus

BACTERIAL PHARYNGOTONSILLITIS

Etiology

Group A beta-haemolytic streptococcus is the most common and important pathogen causing acute bacterial pharyngotonsillitis. This infection most commonly presents in children aged 5-6 yrs.

SYMPTOMS

It is characterized by fever, dry sore throat, cervical adenopathy, dysphagia and odynophagia. The tonsils and

pharyngeal mucosa are erythematous and may be covered with purulent exudate; the tongue may also become red

(strawberry tongue).

DIAGNOSIS

In cases of strongly suspected pharyngitis caused by group A beta hemolytic streptococcus the combination of rapid

strep tests based on ELISA (enzyme-linked immunosorbent assay) or latex agglutination, with a throat culture if negative, increases the sensitivity and specificity of either test alone.

TREATMENT

The primary antibiotic treatment for streptococcal pharyngotonsillitis consists of penicillin.

The syndrome represented by the clinical vignette is infectious mononucleosis.

Epstein-Barr virus (EBV) is the usual cause of heterophile-positive infectious mononucleosis; cytomegalovirus is responsible for a minority of cases.

Rarely, splenic rupture requiring splenectomy can result from splenomegaly and capsular swelling, usually occurring during the 2nd and 3rd weeks of the illness.

Tangier disease is an autosomal co dominant condition caused by mutation in the gene coding for ABCA 1.

These patients have low levels of HDL-C, ApoA – I and LDL-C. There may be a slightly elevated triglyceride levels.

The accumulation of cholesterol in the reticulo endothelial system is responsible for the findings described in the question.

Ref: Harrison, Edition 17, Page – 2423 ; Essential revision notes for MRCP by Philip A Kalra, Edition 3, Page – 333

Parainfluenza virus causes tracheobronchitis and H influenza cause acute epiglottitis.

Ans. is ‘c’ i.e., Loeffler’s serum slope 

.   Fever, cervical lymphadenopathy and grey membrane on the tonsil extending to anterior pillar is suggestive of diphtherial infection. For rapid growth the specimen is inoculated on Loeffler’s serum slope which shows the growth in 4-8 hrs.

Ans. is ‘d’ i.e., Tellurite medium 

– Best diagnosis of any bacteria is made by culture of specimen in the “selective media” and the selective medium for

C. diphtheriae is tellurite agar. Loeffler’s medium shows early growth (in 4-8 hrs), but it is not a selective medium for

C. diphtheriae.

Note :

• Most of the guides have given Loeffler’s medium as correct answer. According to them diphtheria is an emergency, so we should make early diagnosis.

Read text below :

• Green wood has not mentioned Loeffler’s medium at all :

“The recommended media include blood agar and a selective medium containing tellurite”.

• Jawetz writes

“Specific treatment must never be delayed for laboratory reports if the clinical picture is suggestive of diphtheria” – 

• Although growth on Loeffler’s medium helps in making an earlier diagnosis, as we have started treatment on clinical ground, waiting for the growth on tellurite media would be the best option to diagnose the diphtheria as it acts as a selective media.

So

–         For earliest diagnosis of diphtheria – Loeffler’s serum slope

–         For best diagnosis of diphtheria       – Tellurite medium

Ans. is ‘b’ i.e., Blood tellurite media 

Ans. is ‘a’ i.e., Loffelers serum slop 

Diphtheria bacilli grow on Loeffler’s serum slope very rapidly and colonies can be seen in 6-8 hours, long before other bacteria grow.

Ludwigs angina is cellulitis of submandibular space. It does not lead to membrane formation over tonsils.