A Rare Manifestation of Infectious Mononucleosis Tonsillitis

Abstract

The purpose of this case report is to describe a rare case of infectious mononucleosis (IM) hemorrhagic tonsillitis. Our patient presented with acute tonsillitis complicated by spontaneous tonsillar hemorrhage. This is a single case report with a literature review. A 19-year-old male presented to the emergency department with a 10-day history of worsening sore throat, recurrent fevers, malaise, and dysphagia to solids and liquids, as well as a three-day history of epistaxis and hemoptysis. He tested positive for Epstein-Barr virus and rhinovirus. On exam, a “hot potato” voice was noted along with bilateral tonsillar edema, erythema, and hypertrophy. Both tonsils with dry blood coating and no exudates were visualized. Computed tomography (CT) imaging of the neck demonstrated subcutaneous emphysema isolated to the tonsils. Treatment consisted of intravenous antibiotics and steroids, followed by an oral antibiotic, with subsequent full resolution of symptoms. This case illustrates a rare, severe manifestation of IM tonsillitis that radiographically can mimic other more severe soft-tissue neck infections on imaging, such as cervical necrotizing fasciitis. In patients presenting with hematemesis, hemoptysis, and/or epistaxis, along with tonsillar edema, erythema, and hypertrophy, a diagnosis of spontaneous hemorrhagic tonsillitis should be considered. The radiographic findings of soft-tissue emphysema in the deep spaces of the head and neck region may be seen in the setting of IM, mimicking other soft-tissue infections of the deep neck spaces.

Mucosal emphysematous head and neck infections: Scoping review and a case of emphysematous tonsillitis

“…There are also cases in which medical management of these emphysematous infections may be sufficient, particularly in patients who did not develop airway compromise. In three cases, two of emphysematous epiglottitis 1,17 and the other of infectious mononucleosis hemorrhagic tonsillitis, 15 patients showed interval improvement and even complete resolution of symptoms with antibiotics and steroids alone. It is important to note that in these patients, signs of respiratory distress were not reported, their infections were not rapidly progressive on presentation, and they showed improvement when antibiotics were started.…”

“…14 One 19‐year‐old patient with hemorrhagic tonsillitis had known infectious mononucleosis. 15 Otherwise, patients were either previously healthy or had no disclosed medical comorbidities.…”

“… 3 In the case of infectious mononucleosis hemorrhagic tonsillitis, blood cultures confirmed EBV infection. 15 However, it was not disclosed whether any further cultures were directly taken from the tonsils to rule out a superimposed infection.…”

“…In terms of preexisting medical conditions, in a radiologic case series, it was noted that patients with emphysematous infections tended to have immunocompromising conditions, although the specifics of said conditions were not disclosed 14 . One 19‐year‐old patient with hemorrhagic tonsillitis had known infectious mononucleosis 15 . Otherwise, patients were either previously healthy or had no disclosed medical comorbidities.…”

“…Only one patient had cultures of their emphysematous abscess, of which the anaerobic culture speciated to Prevotella melaninogenica and Fusobacterium necrophorum 3 . In the case of infectious mononucleosis hemorrhagic tonsillitis, blood cultures confirmed EBV infection 15 . However, it was not disclosed whether any further cultures were directly taken from the tonsils to rule out a superimposed infection.…”