Symptoms of Bacterial Tonsillitis
Bacterial tonsillitis, most commonly caused by Group A beta-hemolytic streptococcus, presents with sudden-onset sore throat, fever (101-104°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and notably the absence of cough—features that distinguish it from viral pharyngitis. 1
Core Clinical Features
The hallmark symptoms of bacterial tonsillitis include:
- Sudden-onset sore throat with pain on swallowing 1
- Fever ranging from 101°F to 104°F 1
- Tonsillopharyngeal erythema with or without exudates 1
- Tender, enlarged anterior cervical lymph nodes 1
- Absence of cough (a critical distinguishing feature from viral causes) 1, 2
Additional Symptoms
Beyond the core features, bacterial tonsillitis may present with:
- Headache 1
- Abdominal pain, nausea, and vomiting (especially common in children) 1
- Soft palate petechiae ("doughnut lesions") 1
- Beefy red, swollen uvula 1
- Scarlatiniform rash (when scarlet fever develops) 1, 3
Age-Specific Presentations
Children 5-15 years old are the primary age group affected by bacterial tonsillitis, with Group A streptococcus accounting for 15-30% of cases in this population 3, 4. In contrast, only 5-15% of adult tonsillitis cases are bacterial 3, 4.
Younger children (under 3 years) may present differently with less specific findings, such as excoriated nares or purulent nasal discharge rather than classic tonsillar findings 1.
Critical Distinguishing Features from Viral Tonsillitis
The presence of cough, coryza, hoarseness, conjunctivitis, or diarrhea strongly suggests viral rather than bacterial etiology 1, 3. Viral tonsillitis accounts for 70-95% of all tonsillitis cases 4, 5.
Red Flag Symptoms Requiring Urgent Evaluation
Patients with unusually severe presentations warrant immediate assessment for life-threatening complications 3:
- Difficulty swallowing or drooling 3
- Neck tenderness or swelling 3
- Persistent fever with rigors and night sweats 3
- Signs of airway obstruction 3
These symptoms may indicate peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome (particularly in adolescents and young adults) 3, 6.
Clinical Pitfall to Avoid
No single symptom is specific enough to diagnose bacterial tonsillitis 1. Even the presence of tonsillar exudates does not confirm bacterial infection, as viral pathogens (particularly adenovirus and Epstein-Barr virus) commonly cause exudative tonsillitis 7. Therefore, microbiological confirmation with rapid antigen detection testing or throat culture is required before initiating antibiotic therapy 1.
Epidemiological Context
Bacterial tonsillitis typically occurs in winter and early spring in temperate climates, and a history of exposure to a documented case of streptococcal pharyngitis increases diagnostic likelihood 1.