Author(s)
Daniel S Catts, MD
Joshua A Stramiello, MD
Affiliation(s)
Department of Pediatrics, RAF Lakenheath Hospital;
Department of Otolaryngology, Chief of Surgery, Chief of Otolaryngology, RAF Lakenheath Hospital
Abstract:
Introduction: Necrotizing tonsillitis is a rare and poorly understood manifestation of infectious palatine tonsil disease. The literature describing such cases is sporadic and variable in presentation, etiology, and prognosis. This case highlights the diagnostic complexity and clinical implications of bacterially superinfected EBV-positive necrotizing tonsillitis.
Case Description: A 17-year-old female presented with rapid tonsillar enlargement over 24 hours, severe dysphagia/odynophagia, and mild dyspnea. She reported a 7-day history of sore throat with mild improvement until day 5, when symptoms worsened despite outpatient oral penicillin therapy. Examination revealed bilateral 3+ tonsil edema without exudates, as well as tender cervical lymphadenopathy. Rapid streptococcal tests were negative and laboratory evaluation showed leukocytosis with atypical lymphocytosis. Initial computed tomography (CT) imaging demonstrated marked tonsillar enlargement with normal tonsillar perfusion. The patient was admitted for airway monitoring and intravenous antibiotics. Subsequent CT imaging was performed due to progressive tonsillar edema (4+) with severe ecchymosis and gray-white exudates, and identified significant tonsillar hypoperfusion. Cultures grew Haemophilus parainfluenzae and a non-gonococcal Neisseria species. EBV serologies confirmed acute primary infection (positive viral capsid IgM, negative IgG markers). Despite broad-spectrum antibacterial therapy, clinical improvement was delayed and gradual recovery followed over 4 weeks with return of normal appearing palatine tonsils.
Discussion: This case illustrates the normal timely progression of viral tonsillitis complicated by bacterial superinfection. However, the rapid evolution from normal to massively enlarged necrotic tonsils can be intimidating and should raise concern for appropriate antibiotic coverage and airway monitoring. The delay in recovery of tonsil size is likely related to the tonsillar hypoperfusion and associated necrosis. Clinicians should maintain suspicion for EBV in adolescents with progressive, refractory tonsillitis, especially when tonsillar necrosis and hypoperfusion are radiographically evident.