Differentiating tonsillits from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief:

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.

Differentiating Tonsillitis from other Diseases

• 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: Fever of 38 to 40 degrees C.(101-104 degrees F.) Fatigue Sore throat Headache Nausea or Vomiting Abdominal pain Flushed face with perioral pallor (circumoral pallor) Tachycardia (rapid pulse) Lymphadenopathy (enlarged lymph nodes) Punctate red macules on the hard and soft palate and uvula (ie, Forchheimer spots). Bright red tongue with a "strawberry" appearance 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." Peeling also occurs in axilla, groin, and tips of the fingers and toes.
Epstein-Barr Virus	The Epstein-Barr Virus (EBV), also called Human herpesvirus 4 (HHV-4), is a virus of the herpes family (which includes Herpes simplex virus and Cytomegalovirus), and is one of the most common viruses in humans. Most people become infected with EBV, which is often asymptomatic but commonly causes infectious mononucleosis. EBV is named after Michael Epstein and Yvonne Barr, who together with Bert Achong, discovered the virus in 1964. 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: fever sore throat swollen lymph glands. 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.

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.