From the Guidelines
Membranous tonsillitis is most commonly caused by bacterial infections, particularly group A beta-hemolytic streptococcus (GABHS), but can also result from viral infections like Epstein-Barr virus (infectious mononucleosis) or diphtheria in unvaccinated individuals. Evaluation should begin with a thorough history and physical examination, focusing on symptoms like sore throat, fever, difficulty swallowing, and the presence of white or gray exudate on the tonsils. A rapid strep test should be performed first, with a throat culture if the rapid test is negative but clinical suspicion remains high 1. Complete blood count may show leukocytosis in bacterial infections or atypical lymphocytes in mononucleosis. Monospot testing should be considered if mononucleosis is suspected. For suspected diphtheria, specialized cultures on Löffler's medium are necessary. Treatment depends on the identified cause - penicillin V (500 mg twice daily for 10 days) or amoxicillin (500 mg three times daily for 10 days) for streptococcal infections, supportive care for viral causes, and antibiotics plus antitoxin for diphtheria. Proper evaluation is crucial as untreated bacterial tonsillitis can lead to complications like peritonsillar abscess, rheumatic fever, or post-streptococcal glomerulonephritis.
Some key points to consider in the evaluation and management of membranous tonsillitis include:
- The importance of distinguishing between bacterial and viral causes to guide appropriate treatment 1.
- The role of rapid strep testing and throat cultures in diagnosing streptococcal infections 1.
- The consideration of mononucleosis and other viral infections in the differential diagnosis 1.
- The potential for complications such as peritonsillar abscess, rheumatic fever, or post-streptococcal glomerulonephritis if bacterial tonsillitis is left untreated 1.
Overall, a thorough evaluation and appropriate treatment are essential in managing membranous tonsillitis and preventing potential complications. The most recent and highest quality studies support the use of penicillin V or amoxicillin for streptococcal infections, and emphasize the importance of proper evaluation and treatment to prevent complications 1.
From the Research
Etiology of Membranous Tonsillitis
The etiology of membranous tonsillitis is multifactorial, with various studies suggesting the following causes:
- Viral infections, such as Epstein-Barr virus (EBV) and other viral aetiologies, which account for a significant proportion of cases 2
- Bacterial infections, including group A beta-haemolytic streptococcus, which is found in approximately 31.2% of patients with membranous tonsillitis 2
- Other factors, such as reexposure to infected family members or peers, copathogenicity, antibiotic-associated eradication of normal protective pharyngeal flora, and penicillin tolerance, which may contribute to treatment failure 3, 4
Prevalence of Different Aetiologies
The prevalence of different aetiologies of membranous tonsillitis is:
- Group A beta-haemolytic streptococcus: 31.2% 2
- Epstein-Barr virus (EBV): 24.3% 2
- Other viral aetiologies: 44.4% 2
Diagnosis and Treatment
Diagnosis of membranous tonsillitis can be guided by:
- Throat culture: useful for identifying bacterial causes, such as group A beta-haemolytic streptococcus 2
- Peripheral blood smears: useful for identifying Downey cells, which are often seen in EBV-positive patients 2 Treatment of membranous tonsillitis should be guided by the underlying aetiology, with antibiotics reserved for bacterial causes, such as group A beta-haemolytic streptococcus 2