Case No 2

31-year old man admitted to hospital for two-day rising sore throat, odynophagia, and fever

Medical History

Present Illness: Two-day growing pain in neck, left side, pain restrict to almost no swallowing, chill in the morning, cannot fully open the mouth. Examined at Outpatient ENT Dpt, sent to ID Dpt to treat with parenteral antibiotic.

ROS (Review of Systems): Nothing worth considering except mentioned in past history.

FHx: Insignificant for present illness
EHx: Homosexual contact with stable partner, last was 14 days before, oral, negative HIV test three years ago
WSHx: Office worker, single, living with his partner
PM/SHx: hypothyreosis, surgery: left-sided tonsillectomy for peritonsillar abscess 4 years ago, laparoscopic cholecystectomy 5 years ago
Allergies: none
Medications: Letrox 50 µg tbl 0-0-1 tabl qd po
Abuse: 20 cigarettes daily, not using drugs.

Physical Examination

VS: T 38 °C, HR: 122, RR: 18, BP: 126/94, S_pO₂: NA.
General: Alert, oriented, eupneic. Freely mobile. Eutrophic appearance.
Skin: Normal color. No rash, lesions, ulcerations, subcutaneous nodules or induration
Eyes: PERRL, EOMI. No scleral icterus.
ENT: Nares without any discharge. Mucous membranes moist. Oropharynx edematous and slightly erythematous. Left tonsil is enlarged, cleft and covered with numerous white coatings (pseudomembranes), protruding to midline. White coated tongue, foetor ex ore (halitosis).
Neck: Jugular vein filling not increased. Neck is supple, no masses, no thyroid enlargement.
Lymph Nodes: Submandibular lymph nodes are not distinctly swollen, on the left side tender and probably fluctuating.
Cardiovascular: Tachycardia. Heart sounds S1 and S2 normal, no m/g/r. Pulses 2+ equal on both sides.
Lungs: Clear to auscultation bilaterally, normal respiratory effort.
Abdomen: Abdomen muscular, small scars of older date, NT, ND. Liver and spleen not palpable. No rebound or guarding. Normal bowel sounds.
Extremeties: No bilateral cyanosis, clubbing or edema.
MSK: Normal alignment, mobility.
Neurological: Cranial nerves II-XII grossly intact, meningeal signs negative, movements and muscle strength of the extremities symmetrical.

Fig. 1 First view into the oral cavity

Fig. 2 Second view into the oral cavity

Pertinent Laboratory Tests

Hematologic exam:

Blood count: WBC 22.7 10^9/l (4.0-10.0), RBC 4.74 10^12/l (4.00-5.80), Hb 141.0 g/l (135.0-175.0), hct 0.419 1/1 (0.400-0.500), MCV 88.4 fl (82.0-98.0), MCH 29.7 pg (28.0-34.0), MCHC 0.337 kg/l (0.320-0.360) PLT 213.0 10^9/l (150.0-400.0).
Differential leukocyte count:
(automated) Ne 0.83, Ly 0.08, Mo 0.08, Eo 0.00, Ba 0.00.
(microscopical) Ne seg 0.75, Ne band 0.09, Ly 0.09, Mmo 0.07.

Biochemic exam:

Urine chem.: U-pH: 5.5 U-SG: *1.028 kg/l U-Glu: 0 arb.unit U-Keto: *1 arb.unit U-Prot: 1 arb.unit U-Bil: 0 arb.unit U-Uro: 0 arb.unit U-Krev: * 1 arb.unit U-Nit: 0 arb.unit U-Ask: 0 arb.unit U-Ery: * 5 /ul U-Leu: 5 /ul
Biochemistry of plasma and serum: Na⁺ 136 mmol/l (132-149), K⁺ 3.80 mmol/l (3.80-5.50), Cl^- 103 mmol/l(97-108), urea 6.30 mmol/l (3.20-7.40), creatinin 81 umol/l (64-110), AST 0.32 µkat/l (<0.65), ALT 0.47 µkat/l (<0.80), ALP 1.27 µkat/l (0.50-2.00), GGT 0.57 µkat/l (<1.10), CRP 251.9 mg/l (0.0-8.0)

Microbiology laboratory tests:

Molecular genetic detection of STI's: Throat swab: Chlamydia trachomatis: negative
Syphilis serology: RPR test negative; TPPA: negative
Herpetic viruses serology:
CMV: anti CMV KFR 1:32/64+- titr, a-CMV-IgM negative positivity index (IP) (cut-off = 1), CMV-IgG semiquant 917.7 positive AU/ml (cut-off = 6), CMV - avidity - not completed
EBV: anti EBV EBNA-1 IgM ELISA not completed EBV VCA-IgM negative IP, EBV VCA-IgG positive IP, EBV EBNA-IgG positive IP, a-EBV EA-IgG negative IP (cut-off = 1)
HIV serology: anti-HIV 1,2 negative, p24 negative

Imaging and Other Investigations

Imaging:

Neck CT scan: after right-sided tonsillectomy, left tonsil very enlarged (3×4 cm), no signs of either intra- or peritonsillar abscess, no evidence of laryngeal swelling, multiple swollen lymph nodes of groups I-V without signs of colliquation.

Fig. 3 Neck CT scan

Diagnostic Conclusion

Tonsillitis (angina) ulceromembranosa (tonsillae solitariae l. sin.)
St.p. tonsillectomiam l. dx. ante annos IV
Hypothyreosis - substitutio hormonalis
Nicotinismus
St.p. cholecystectomiam laparoscopicam ante annos V

Treatment

Propose medicamentous treatment

Task

None