Tag: Acute Tonsilitis

Acute Tonsilitis

Acute Tonsilitis


ACUTE TONSILLITIS

TYPES AND CLINCAL FEATURES OF ACUTE TONSILLITIS

Types:

  • Acute Follicualr Tonsillitis:where inflammatory exudate from the crypts marks the reddened surface with whitish spots.
  • Acute Parenchymatous Tonsillitis:when the whole tonsil is uniformly congested.
  • Acute Membranous Tonsillitis:in which exudate from the cyrpts coalesces to form a membrane over the surface.

Symptoms:

  • Throat pain-aggravated on swallowing,may get referred to the ear via Glossopharyngeal nerve
  • Fever,Malaise and Headache
  • Neck swelling-Jugulodigastric Lymph node enlargement.
  • Difficulty in swallowing

Signs:

  • Fever,Tachycardia.
  • Tonsils are enlarged and congested.
  • Pharynx is also inflammed.
  • Tender and enlarged jugulo-digastric lymph nodes.
  • Breath is foetid and tongue is coated.

COMPLICATIONS OF ACUTE TONSILLITIS

Local:

  • Chronic Tonsillitis
  • Peritonsillar Abscess(Quinsy) and Parapharyngeal Abscess
  • Suppurative cervical Lymphadenitis
  • Acute Otitis Media

Systemic

  • Rheumatic fever
  • Acute Glomerulonephritis
  • Infective Endocarditis

DIIFERENTIAL DIAGNOSIS OF ENLARGED TONSILS

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-may be covered by grey-white membrane on the tonsils; 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.

INFECTIOUS MONONUCLEOSIS

  • Epstein-Barr virus (EBV) is the usual cause of heterophile-positive infectious mononucleosis; cytomegalovirus is responsible for a minority of cases.
  • Patient presents with fatigue and difficulty swallowing.
  • Physical exam reveals exudative tonsillitis-may be covered by grey-white membrane on the tonsils, palatal petechiae, cervical lymphadenopathy, and tender hepatosplenomegaly.
  • A complete blood count reveals mild anemia, lymphocytosis with about 30% of the lymphocytes exhibiting atypical features, and a mild thrombocytopenia.
  • Coombs’ test is positive.
  • Splenic rupture is the most likely complication.

DIPHTHERIA

  • 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..
  • Loeffler’s medium shows early growth (in 4-8 hrs), but it is not a selective medium for C. diphtheriae.
  • Best diagnosis of any bacteria is made by culture of specimen in the “selective media” and the selective medium forC. diphtheriae is tellurite agar.

TANGIER DISEASE

  • It 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 Mononeuritis multiplex, hepatosplenomegaly,enlarged orange coloured tonsils. 

WHITISH MEMBRANE IN THE THROAT AND TONSILS

  • Pyogenic organisms viz. Streptococci, Staphylococci causing membranous tonsillitis
  • Diphtheria
  • Vincent’s angina (Caused by fusiform bacilli and spirochetes: Borrelia vincentii)
  • Candidiasis/monoliasis/oral thrush
  • Infectious mononucleosis
  • Agranulocytosis
  • Leukemia
  • Aphthous ulcers
  • Traumatic ulcers
Exam Question
 
  • During Tonsillitis, pain in the ear is due to involvement of Glossopharyngeal Nerve.
  • Splenic Rupture in the most likely complication in a patient suffering from exudative tonsillitis,palatal petechiae, cervical lymphadenopathy,tender hepatosplenomegaly,complete blood count revealing mild anemia, lymphocytosis with about 30% of the lymphocytes exhibiting atypical features, and a mild thrombocytopenia and Coombs’ test is positive suggestive of infectious mononucleosis.
  • Pathognomonic enlarged, grayish yellow or orange tonsils are seen in Tangier disease.
  • Commonest causative organism for acute tonsillitis is Group A beta Hemolytic Streptococcus.
  • 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.
  • but diagnosis is best made by culture in Tellurite medium
Don’t Forget to Solve all the previous Year Question asked on Acute Tonsilitis

Acute Tonsilitis

Acute Tonsilitis

Q. 1

During Tonsillitis, pain in the ear is due to involvement of?

 A

Vagus Nerve

 B

Chorda tympani Nerve

 C

Glossopharyngeal Nerve

 D

Hypoglossal Nerve

Q. 1

During Tonsillitis, pain in the ear is due to involvement of?

 A

Vagus Nerve

 B

Chorda tympani Nerve

 C

Glossopharyngeal Nerve

 D

Hypoglossal Nerve

Ans. C

Explanation:

Q. 2 A  6  years  old  female  child  presents  with severe pain in throat and odynophagia, since one week General examination revealed, cervical lymphadenopathy, but no signs or symptoms of upper airway obstruction. Intra-oral examination revealed swelling, redness and protrusion of both tonsils,    Most    common    causathe    agent    is: 
 A Haemolytic streptococcus
 B Non-haemolytic streptococcus
 C H. influenza
 D Staphylococci
Q. 2 A  6  years  old  female  child  presents  with severe pain in throat and odynophagia, since one week General examination revealed, cervical lymphadenopathy, but no signs or symptoms of upper airway obstruction. Intra-oral examination revealed swelling, redness and protrusion of both tonsils,    Most    common    causathe    agent    is: 
 A Haemolytic streptococcus
 B Non-haemolytic streptococcus
 C H. influenza
 D Staphylococci
Ans. A

Explanation:

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.


Q. 3

A child presents with a white patch over the tonsils; diagnosis is best made by culture in:

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Q. 3

A child presents with a white patch over the tonsils; diagnosis is best made by culture in:

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Ans. A

Explanation:

In the child presenting with a white patch over the tonsil, we suspect a diagnosis of ‘diphtheria’. Usual media used for cultivation of Diphtheria are Loeffler’s serum slope & tellurite blood agar.
 
Ref: Text Book of Microbilogy By Ananthanarayan, 6th Edition, Page 215 and 8th Edition, Page 233

Q. 4

A febrile 23-year-old college student presents with fatigue and difficulty swallowing. Physical exam reveals exudative tonsillitis, palatal petechiae, cervical lymphadenopathy, and tender hepatosplenomegaly. A complete blood count reveals mild anemia, lymphocytosis with about 30% of the lymphocytes exhibiting atypical features, and a mild thrombocytopenia. Coombs’ test is positive. Which of the following is the most likely complication of this syndrome?

 A

Acute cholecystitis

 B

Ascending cholangitis

 C

Diarrhea

 D

Splenic rupture

Q. 4

A febrile 23-year-old college student presents with fatigue and difficulty swallowing. Physical exam reveals exudative tonsillitis, palatal petechiae, cervical lymphadenopathy, and tender hepatosplenomegaly. A complete blood count reveals mild anemia, lymphocytosis with about 30% of the lymphocytes exhibiting atypical features, and a mild thrombocytopenia. Coombs’ test is positive. Which of the following is the most likely complication of this syndrome?

 A

Acute cholecystitis

 B

Ascending cholangitis

 C

Diarrhea

 D

Splenic rupture

Ans. D

Explanation:

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.

Acute cholecystitis is not associated with infectious mononucleosis.
The most frequently isolated pathogens are E. coli, Klebsiella spp., group D Streptococcus, Staphylococcus spp., and Clostridium spp.
Ascending cholangitis is not associated with infectious mononucleosis.
Cholangitis usually presents with biliary colic, jaundice, and spiking fever with chills (Charcot’s triad).
Blood cultures are usually positive (E. coli is a common isolate), with an accompanying leukocytosis.

AIDS-related cholangitis has been reported, presenting with abdominal pain and obstructive liver symptoms. Potential etiologic agents include Cytomegalovirus, Cryptosporidium parvum, and Microsporidia, including Enterocytozoon cuniculi.

Diarrhea is not usually produced by infectious mononucleosis.

Q. 5

An 8 year old child is referred to you with history of Mononeuritis multiplex. On examination you find that there is hepatosplenomegaly. Examination of the oral cavity and pharynx revealed enlarged orange coloured tonsils. Which of the following statement regarding the above condition is false?

 A

It is a case of Tangier diaese

 B

The plasma LDL – c levels will be low

 C

It is an autosomal recessive condition

 D

It is caused by ABCA1 deficiency

Q. 5

An 8 year old child is referred to you with history of Mononeuritis multiplex. On examination you find that there is hepatosplenomegaly. Examination of the oral cavity and pharynx revealed enlarged orange coloured tonsils. Which of the following statement regarding the above condition is false?

 A

It is a case of Tangier diaese

 B

The plasma LDL – c levels will be low

 C

It is an autosomal recessive condition

 D

It is caused by ABCA1 deficiency

Ans. C

Explanation:

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


Q. 6

Commonest causative organism for acute tonsillitis is which of the following?

 A

B streptococci

 B

Parainfluenza virus

 C

H influenza

 D

Corynebacterium

Q. 6

Commonest causative organism for acute tonsillitis is which of the following?

 A

B streptococci

 B

Parainfluenza virus

 C

H influenza

 D

Corynebacterium

Ans. A

Explanation:

Parainfluenza virus causes tracheobronchitis and H influenza cause acute epiglottitis.


Q. 7

A 12-year-old child presents with fever and cervical lymphadenopathy. Oral examination shows a grey membrane on the right tonsil extending to the anterior pillar. Which of the following medium will be ideal for the culture of the throat swab for a rapid identification of the pathogen –

 A

Nutrient agar

 B

Bloodagar

 C

Loffler’s serum slope

 D

Lowenstein Jensen medium

Q. 7

A 12-year-old child presents with fever and cervical lymphadenopathy. Oral examination shows a grey membrane on the right tonsil extending to the anterior pillar. Which of the following medium will be ideal for the culture of the throat swab for a rapid identification of the pathogen –

 A

Nutrient agar

 B

Bloodagar

 C

Loffler’s serum slope

 D

Lowenstein Jensen medium

Ans. C

Explanation:

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.


Q. 8

A child presents with a white patch over the tonsils, diagnosis is best made by culture in –

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Q. 8

A child presents with a white patch over the tonsils, diagnosis is best made by culture in –

 A

Loeffler medium

 B

LJ medium

 C

Blood agar

 D

Tellurite medium

Ans. D

Explanation:

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



Q. 9

A child has respiratory infection with membrane over Peritonsillar area. Swab was taken from the local area. The appropriate media for culture is –

 A

L.J. media

 B

Blood tellurite media

 C

Cary media

 D

Loeffler serum slope

Q. 9

A child has respiratory infection with membrane over Peritonsillar area. Swab was taken from the local area. The appropriate media for culture is –

 A

L.J. media

 B

Blood tellurite media

 C

Cary media

 D

Loeffler serum slope

Ans. B

Explanation:

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


Q. 10

A child come with fever, cold, cough, membrane over tonsils; nasal swab is taken, culture should be done on which medium for earliest diagnosis ‑

 A

Loffelers serum slop

 B

L. J. media

 C

MC Conkey’s Agar

 D

Citrate media

Q. 10

A child come with fever, cold, cough, membrane over tonsils; nasal swab is taken, culture should be done on which medium for earliest diagnosis ‑

 A

Loffelers serum slop

 B

L. J. media

 C

MC Conkey’s Agar

 D

Citrate media

Ans. A

Explanation:

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.


Q. 11

All of the following cause a gray-white membrane on the tonsils, except:

 A

Infectious mononucleosis

 B

Ludwig’s angina

 C

Streptococcal tonsillitis

 D

Diphtheria

Q. 11

All of the following cause a gray-white membrane on the tonsils, except:

 A

Infectious mononucleosis

 B

Ludwig’s angina

 C

Streptococcal tonsillitis

 D

Diphtheria

Ans. B

Explanation:

 

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

 



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