BackgroundThe two major indications for tonsillectomy are recurrent tonsillitis (RT) and peritonsillar abscess (PTA). Unlike PTAs, which are primarily treated surgically, RT is often cured by tonsillectomy only after a series of failed drug therapy attempts. Although the bacteriological background of RT has been studied, the reason for the lack of success of conservative therapeutic approaches is not well understood.MethodsIn a prospective study, tonsil specimens from 130 RT patients and 124 PTA patients were examined for the presence of extra- and intracellular bacteria using antibiotic protection assays. Staphylococcus aureus isolates from RT patients were characterized by pulsed-field gel electrophoresis (PFGE), spa-typing and MSCRAMM-gene-PCR. Their ability for biofilm formation was tested and their cell invasiveness was confirmed by a flow cytometric invasion assay (FACS), fluorescent in situ hybridization (FISH) and immunohistochemistry.Findings S. aureus was the predominant species (57.7%) in RT patients, whereas Streptococcus pyogenes was most prevalent (20.2%) in PTA patients. Three different assays (FACS, FISH, antibiotic protection assay) showed that nearly all RT-associated S. aureus strains were located inside tonsillar cells. Correspondingly, the results of the MSCRAMM-gene-PCRs confirmed that 87% of these S. aureus isolates were invasive strains and not mere colonizers. Based upon PFGE analyses of genomic DNA and on spa-gene typing the vast majority of the S. aureus isolates belonged to different clonal lineages.ConclusionsOur results demonstrate that intracellular residing S. aureus is the most common cause of RT and indicate that S. aureus uses this location to survive the effects of antibiotics and the host immune response. A German translation of the Abstract is provided as supplementary material (Abstract S1).

A women presented with a systematized sebaceous nevus of the head and neck. She had developed multiple basal cell carcinomas and sebaceomas in the nevus over the past 3 years after a period of about 55 years without any changes. Detailed medical history and physical examination revealed a constellation of findings suggesting a syndrome. Besides ptosis and a congenital, vascular corneal clouding at the right, there was hypoplasia of the right maxillary sinus, a right labyrinthine deafness and recurrent inguinal herniae on the right. The Schimmelpenning-Feuerstein-Mims-Syndrome was diagnosed.

The Burkholderia cepacia complex comprises bacteria typically responsible for respiratory infections in immunocompromised and cystic fibrosis patients. However, these bacteria are rarely associated with infections in immunocompetent patients. In the presented case reports of two nonhospitalized immunocompetent female patients who underwent tonsillectomy as the ultimate therapy for recurrent tonsillopharyngitis, Burkholderia cenocepacia were demonstrated in the surgically removed tonsils. The clinical, histological, and microbiological findings of both cases are presented. The etiological relevance and the probable success of antibiotic treatment versus surgical measures are discussed.