Can a patient with a severe bacterial infection on the left tonsil, presenting with visible grey exudate/pus and a foul odor, and being treated with clindamycin (due to penicillin (pcn) allergy) 300mg orally (po) three times a day (tid) for 10 days, have a sexually transmitted disease (STD) as the cause of infection, given no culture is available?

Can STDs Cause Severe Tonsil Infection with Grey Exudate?

Yes, sexually transmitted infections can cause severe tonsillar infections with grey exudate and foul odor—specifically gonococcal pharyngitis (Neisseria gonorrhoeae) and less commonly syphilitic pharyngitis (Treponema pallidum). However, your current clindamycin regimen is appropriate for typical bacterial tonsillitis in a penicillin-allergic patient.

STDs That Can Cause Tonsillar Infections

Gonococcal Pharyngitis

• Neisseria gonorrhoeae can infect the pharynx through orogenital contact and presents with pharyngitis, though it is often asymptomatic 1
• Gonococcal pharyngeal infections are more difficult to eradicate than urogenital infections, with few antimicrobial regimens reliably curing >90% of infections 1
• The grey exudate and foul odor you describe could be consistent with gonococcal pharyngitis, though this presentation is not pathognomonic 1
• Recommended treatment for gonococcal pharyngitis: Ceftriaxone 125 mg IM single dose PLUS azithromycin 1 g orally single dose (or doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection cannot be ruled out) 1

Syphilitic Pharyngitis

• Primary or secondary syphilis can present with pharyngeal involvement, including grey patches or mucous patches in the oropharynx 1
• This is less common than gonococcal pharyngitis but should be considered in the differential diagnosis 1

Other Considerations

• Chlamydia trachomatis rarely causes pharyngeal infection, and when it does, it is typically asymptomatic 1
• Herpes simplex virus (HSV) can cause pharyngitis but typically presents with vesicles and ulcers rather than grey exudate 1

Your Current Treatment Assessment

Clindamycin Appropriateness

• Your clindamycin 300 mg PO TID x 10 days is appropriate for Group A streptococcal pharyngitis in a penicillin-allergic patient 1
• Clindamycin resistance among GAS isolates in the United States is approximately 1%, making it a reasonable agent 1
• Clindamycin has been shown to be highly effective (100% eradication) in patients who failed penicillin therapy for streptococcal pharyngotonsillitis 2, 3

Limitations of Current Therapy

• Clindamycin does NOT adequately cover gonococcal pharyngitis 1
• If this is gonococcal pharyngitis, the infection will likely persist despite clindamycin therapy 1

Clinical Decision Algorithm

When to Suspect STD-Related Pharyngitis

Look for these specific features:

• Sexual history: Recent orogenital contact, multiple partners, or partner with known STD 1
• Unilateral presentation: Gonococcal pharyngitis can be asymmetric (you mention left tonsil only) 1
• Lack of response to standard therapy: Persistence after 48-72 hours of appropriate antibiotics 1
• Associated symptoms: Concurrent urethritis, cervicitis, or genital symptoms suggest disseminated gonococcal infection 1

Recommended Action Steps

If STD risk factors are present:

1. Obtain sexual history including recent orogenital contact 1
2. Culture the pharynx for Neisseria gonorrhoeae on appropriate media (Thayer-Martin or chocolate agar) 1
3. Consider empiric treatment for gonococcal pharyngitis if high suspicion: Ceftriaxone 125 mg IM single dose PLUS azithromycin 1 g orally single dose 1
4. Test for other STDs: Syphilis serology (RPR/VDRL), HIV, and consider urethral/cervical testing for gonorrhea and chlamydia 1
5. Evaluate and treat sexual partners within the past 60 days 1

If no STD risk factors:

1. Continue clindamycin as prescribed for the full 10-day course 1
2. Reassess in 48-72 hours: If no improvement, consider culture for resistant organisms or alternative diagnoses 1
3. Consider other causes: Fusobacterium necrophorum (Lemierre's syndrome), peritonsillar abscess, or diphtheria (if unvaccinated) 1

Critical Pitfalls to Avoid

• Do not assume all grey exudate is streptococcal pharyngitis—gonococcal pharyngitis can present identically and requires different treatment 1
• Do not rely on clinical presentation alone to rule out STDs—many gonococcal pharyngeal infections are asymptomatic or have nonspecific symptoms 1
• Do not use spectinomycin for pharyngeal gonorrhea—it is only 52% effective against pharyngeal infections 1
• Do not use fluoroquinolones empirically for gonococcal pharyngitis without susceptibility testing due to widespread resistance 1
• Without culture, you cannot definitively rule out gonococcal pharyngitis in a patient with appropriate risk factors 1

Bottom Line

The grey exudate and foul odor could represent gonococcal pharyngitis if there is a history of orogenital contact. Your clindamycin regimen is appropriate for typical bacterial pharyngitis but will not treat gonorrhea. If the patient has any STD risk factors or fails to improve within 48-72 hours, obtain pharyngeal cultures for gonorrhea and consider empiric treatment with ceftriaxone plus azithromycin 1. Sexual partners should be evaluated and treated if gonorrhea is confirmed 1.