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Tonsillitis differential diagnosis

Overview

Tonsillitis is a bacterial or viral infection that causes inflammation and swelling of the tonsils. Most often, this infection is characterized by two distinct traits; sore throat and difficulty swallowing. However, other infections such as Scarlet fever and Epstein-Barr virus may present in a similar fashion. Thus prior to any treatment of the infection, it is important to perform diagnostic testing to identify the correct infection.

Differential Diagnosis

  • There are two diseases that are distinguished to present similarly to Tonsillitis; they are Scarlet fever and Epstein Barr Virus.
Disease Definition
Scarlet Fever
  • Streptococcus pyogenes (group A strep) is responsible for scarlet fever. It can also cause simple angina, erysipelas and serious toxin-mediated syndromes like necrotizing fasciitis and the so-called streptococal toxic shock-like syndrome. The virulence of group A strep seems to be increasing lately. The exanthem of scarlatina is thought to be due to erythrogenic toxin production by specific streptococcal strains in a nonimmune patient. Along with erythrogenic toxins, the Group A strep produces several toxins and enzymes. Two of the most important are the streptolysins O and S. Streptolysin O, an hemolytic, thermolabile and immunogenic toxin, is the base of an assay for scarlatina and erysipelas – the anti-streptolysin O titer.
  • Early symptoms indicating the onset of scarlet fever can include:

[1] [2]

Rash

  • Characteristic rash, which:
  • is fine, red, and rough-textured; it blanches upon pressure
  • Pastia lines (where the rash becomes confluent in the arm pits and groins) appear and persist after the rash is gone
  • The rash begins to fade three to four days after onset and desquamation (peeling) begins. “This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later and can last up to a month.”[2] Peeling also occurs in axilla, groin, and tips of the fingers and toes.[1]
Epstein-Barr Virus

EBV is named after Michael Epstein and Yvonne Barr, who together with Bert Achong, discovered the virus in 1964.[3]

  • Epstein-Barr virus is ubiquitous across the globe and the strongest causative agent for the manifestation of infectious mononucleosis. Commonly, a person is first exposed to the virus during or after adolescence. Though once deemed “The Kissing Disease”, recent research has shown that transmission of mononucleosis not only occurs from intimate contact with infected saliva, but also from contact with the airborne virus.
  • Symptoms of infectious mononucleosis are:
  • Sometimes, a splenomegaly or hepatomegaly may develop. Heart problems or involvement of the central nervous system occurs only rarely, and infectious mononucleosis is almost never fatal. There are no known associations between active EBV infection and problems during pregnancy, such as miscarriages or birth defects. Although the symptoms of infectious mononucleosis usually resolve in 1 or 2 months, EBV remains dormant or latent in a few cells in the throat and blood for the rest of the person’s life. Periodically, the virus can reactivate and is commonly found in the saliva of infected persons. This reactivation usually occurs without symptoms of illness.

Tonsillitis must be differentiated from other causes of dysphagia and fever.

Variable Croup Epiglottitis Pharyngitis Bacterial tracheitis Tonsilitis Retropharyngeal abscess Subglottic stenosis
Presentation Cough ✔ — Sore throat, pain on swallowing, fever, headache, abdominal pain, nausea and vomiting Barking cough, stridor,

fever, chest pain,

ear pain, difficulty breathing, headache, dizziness.

Sore throat, pain on swallowing, fever, headache, cough Neck pain, stiff neck, torticollis

fever, malaise, stridor, and barking cough

Depends on severity. May have respiratory distress at birth, exercise-induced dyspnea, intermittent wheezing. Inspiratory stridor. [4]
Stridor ✔ ✔
Drooling — ✔
Others are Hoarseness, Difficulty breathing, symptoms of the common cold, Runny nose, Fever Other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice
Causes Parainfluenza virus H. influenza type b, beta-hemolytic streptococci, Staphylococcus aureus, fungi and viruses. Group A beta-hemolytic streptococcus. Staphylococcus aureus Most common cause is viral including adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus. Second most common causes are bacterial; Group A streptococcal bacteria,[5]  Polymicrobial infection. Mostly; Streptococcus pyogenes, Staphylococcus aureus and respiratory anaerobes (example; Fusobacteria, Prevotella, and Veillonella species)[6][7][8][9][10][11] Congenital, trauma
Physical exams findings Suprasternal and intercostal indrawing,[12] Inspiratory stridor[13], expiratory wheezing,[13] Sternal wall retractions[14] Cyanosis, Cervical lymphadenopathy, Inflammed epiglottis Inflammed pharynx with or without exudate Subglottic narrowing with purulent secretions in the trachea[15][16] Fever, especially 100°F or higher.[17][18]Erythema, edema and Exudate of the tonsils.[19] cervical lymphadenopathy, Dysphonia.[20] Child may be unable to open the mouth widely. May have enlarged

cervical lymph nodes and neck mass.

Signs of respiratory distress, intermittent wheezing. Inspiratory stridor. [4]
Age commonly affected Mainly 6 months and 3 years old

rarely, adolescents and adults[21]

Used to be mostly found in

pediatric age group between 3 to 5 years,

however, recent trend favors adults

as most commonly affected individuals[22]

with a mean age of 44.94 years.

Mostly in children and young adults,

with 50% of cases identified

between the ages of 5 to 24 years.[23]

Mostly during the first six years of life Primarily affects children

between 5 and 15 years old.[24]

Mostly between 2-4 years, but can occur in other age groups.[25][26] May be congenital congenital or acquired. Mean age in acquired is 54.1 years[27]
Imaging finding Steeple sign on neck X-ray Thumbprint sign on neck x-ray — Lateral neck xray shows intraluminal membranes and tracheal wall irregularity. Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[28][29][30] On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen[31][32] Bronchoscopy reveals subglottic stenosis. Computed tomography may reveal a concentric stenotic tracheal segment.[33]
Treatment Dexamethasone and nebulised epinephrine Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[34][35] Antimicrobial therapy mainly penicillin-based and analgesics. Airway maintenance and antibiotics Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases. Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin. Endoscopic balloon dilation for patients with low-grade subglottic stenosis,[36] glucocorticoid injections, and resection.[37]

Differentiating between Common Misdiagnosis

Scarlet Fever

  • Scarlet fever may be ruled out in testing for specific bacteria that produce the erythrogenic toxin.
  • This toxin is ultimately the underlying cause of Scarlet fever.
  • In its absence, Scarlet fever would only present as purulent tonsillitis.

Epstein-Barr

  • Differentiated based on clinical manifestations.
  • May be responsible for prolonged fatigue.
  • Tonsillectomy may lead to further complications including an increased risk of hemorrhaging.

References

  1. ↑ 1.0 1.1 Balentine J and Kessler D (March 7, 2006). “Scarlet Fever”. eMedicine. emerg/518.
  2. ↑ 2.0 2.1 Dyne P and McCartan K (October 19, 2005). “Pediatrics, Scarlet Fever”. eMedicine. emerg/402.
  3. ↑ Epstein MA, Achong BG, Barr YM (1964). “Virus particles in cultured lymphblasts from Burkitt’s Lymphoma”. Lancet. 1: 702–3. PMID 14107961.
  4. ↑ 4.0 4.1 Nussbaumer-Ochsner Y, Thurnheer R (2015). “IMAGES IN CLINICAL MEDICINE. Subglottic Stenosis”. N Engl J Med. 373 (1): 73. doi:10.1056/NEJMicm1404785. PMID 26132943.
  5. ↑ Putto A (1987). “Febrile exudative tonsillitis: viral or streptococcal?”. Pediatrics. 80 (1): 6–12. PMID 3601520.
  6. ↑ Cheng J, Elden L (2013). “Children with deep space neck infections: our experience with 178 children”. Otolaryngol Head Neck Surg. 148 (6): 1037–42. doi:10.1177/0194599813482292. PMID 23520072.
  7. ↑ Abdel-Haq N, Quezada M, Asmar BI (2012). “Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus”. Pediatr Infect Dis J. 31 (7): 696–9. doi:10.1097/INF.0b013e318256fff0. PMID 22481424.
  8. ↑ Inman JC, Rowe M, Ghostine M, Fleck T (2008). “Pediatric neck abscesses: changing organisms and empiric therapies”. Laryngoscope. 118 (12): 2111–4. doi:10.1097/MLG.0b013e318182a4fb. PMID 18948832.
  9. ↑ Brook I (2004). “Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses”. J Oral Maxillofac Surg. 62 (12): 1545–50. PMID 15573356.
  10. ↑ Wright CT, Stocks RM, Armstrong DL, Arnold SR, Gould HJ (2008). “Pediatric mediastinitis as a complication of methicillin-resistant Staphylococcus aureus retropharyngeal abscess”. Arch Otolaryngol Head Neck Surg. 134 (4): 408–13. doi:10.1001/archotol.134.4.408. PMID 18427007.
  11. ↑ Asmar BI (1990). “Bacteriology of retropharyngeal abscess in children”. Pediatr Infect Dis J. 9 (8): 595–7. PMID 2235179.
  12. ↑ Johnson D (2009). “Croup”. BMJ Clin Evid. 2009. PMC 2907784. PMID 19445760.
  13. ↑ 13.0 13.1 Cherry, James D. (2008). “Croup”. New England Journal of Medicine. 358 (4): 384–391. doi:10.1056/NEJMcp072022. ISSN 0028-4793.
  14. ↑ Johnson D (2009). “Croup”. BMJ Clin Evid. 2009. PMC 2907784. PMID 19445760.
  15. ↑ Liston SL, Gehrz RC, Siegel LG, Tilelli J (1983). “Bacterial tracheitis”. Am J Dis Child. 137 (8): 764–7. PMID 6869336.
  16. ↑ Liston SL, Gehrz RC, Jarvis CW (1981). “Bacterial tracheitis”. Arch Otolaryngol. 107 (9): 561–4. PMID 7271556.
  17. ↑ Tonsillitis. Medline Plus. https://www.nlm.nih.gov/medlineplus/ency/article/001043.htm. Accessed May 2nd, 2016.
  18. ↑ “Tonsillitis – NHS Choices”.
  19. ↑ Stelter K (2014). “Tonsillitis and sore throat in children”. GMS Curr Top Otorhinolaryngol Head Neck Surg. 13: Doc07. doi:10.3205/cto000110. PMC 4273168. PMID 25587367.
  20. ↑ “Tonsillitis – Symptoms – NHS Choices”.
  21. ↑ Tong MC, Chu MC, Leighton SE, van Hasselt CA (1996). “Adult croup”. Chest. 109 (6): 1659–62. PMID 8769531.
  22. ↑ Lichtor JL, Roche Rodriguez M, Aaronson NL, Spock T, Goodman TR, Baum ED (2016). “Epiglottitis: It Hasn’t Gone Away”. Anesthesiology. 124 (6): 1404–7. doi:10.1097/ALN.0000000000001125. PMID 27031010.
  23. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  24. ↑ Sharav, Yair; Benoliel, Rafael (2008). Orofacial Pain and Headache. Elsevier. ISBN 0723434123.
  25. ↑ Craig FW, Schunk JE (2003). “Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management”. Pediatrics. 111 (6 Pt 1): 1394–8. PMID 12777558.
  26. ↑ Coulthard M, Isaacs D (1991). “Neonatal retropharyngeal abscess”. Pediatr Infect Dis J. 10 (7): 547–9. PMID 1876473.
  27. ↑ Nicolli EA, Carey RM, Farquhar D, Haft S, Alfonso KP, Mirza N (2017). “Risk factors for adult acquired subglottic stenosis”. J Laryngol Otol. 131 (3): 264–267. doi:10.1017/S0022215116009798. PMID 28007041.
  28. ↑ Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H; et al. (2016). “Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy”. Auris Nasus Larynx. 43 (2): 182–6. doi:10.1016/j.anl.2015.09.014. PMID 26527518.
  29. ↑ Nogan S, Jandali D, Cipolla M, DeSilva B (2015). “The use of ultrasound imaging in evaluation of peritonsillar infections”. Laryngoscope. 125 (11): 2604–7. doi:10.1002/lary.25313. PMID 25946659.
  30. ↑ Fordham MT, Rock AN, Bandarkar A, Preciado D, Levy M, Cohen J; et al. (2015). “Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess”. Laryngoscope. 125 (12): 2799–804. doi:10.1002/lary.25354. PMID 25945805.
  31. ↑ Philpott CM, Selvadurai D, Banerjee AR (2004). “Paediatric retropharyngeal abscess”. J Laryngol Otol. 118 (12): 919–26. PMID 15667676.
  32. ↑ Vural C, Gungor A, Comerci S (2003). “Accuracy of computerized tomography in deep neck infections in the pediatric population”. Am J Otolaryngol. 24 (3): 143–8. PMID 12761699.
  33. ↑ Nussbaumer-Ochsner Y, Thurnheer R (2015). “IMAGES IN CLINICAL MEDICINE. Subglottic Stenosis”. N Engl J Med. 373 (1): 73. doi:10.1056/NEJMicm1404785. PMID 26132943.
  34. ↑ Nickas BJ (2005). “A 60-year-old man with stridor, drooling, and “tripoding” following a nasal polypectomy”. J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
  35. ↑ Wick F, Ballmer PE, Haller A (2002). “Acute epiglottis in adults”. Swiss Med Wkly. 132 (37–38): 541–7. PMID 12557859.
  36. ↑ Cui PC, Luo JS, Zhao DQ, Guo ZH, Ma RN (2016). “[Management of subglottic stenosis in children with endoscopic balloon dilation]”. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 51 (4): 286–8. doi:10.3760/cma.j.issn.1673-0860.2016.04.009. PMID 27095722.
  37. ↑ Nussbaumer-Ochsner Y, Thurnheer R (2015). “IMAGES IN CLINICAL MEDICINE. Subglottic Stenosis”. N Engl J Med. 373 (1): 73. doi:10.1056/NEJMicm1404785. PMID 26132943.

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