What is the appropriate management for a patient with acute membranous tonsillitis?

Acute Membranous Tonsillitis Management

Acute membranous tonsillitis requires immediate consideration of diphtheria as the primary differential diagnosis, followed by Group A Streptococcus (GAS) pharyngitis, Epstein-Barr virus (infectious mononucleosis), and other bacterial pathogens—with management hinging on rapid diagnostic testing and empiric antibiotic therapy while awaiting culture results.

Immediate Diagnostic Approach

Critical First Steps

• Obtain a throat swab for bacterial culture specifically requesting Corynebacterium diphtheriae testing before initiating antibiotics, as diphtheria remains a significant cause of membranous tonsillitis even in developed countries 1, 2.
• Perform rapid antigen detection test (RADT) for Group A Streptococcus simultaneously, as GAS accounts for 15-30% of bacterial tonsillitis in children aged 5-15 years and 5-15% in adults 3.
• Document the following clinical features that distinguish bacterial from viral etiology: sudden onset of sore throat, fever >38°C, tonsillar exudates forming a confluent membrane, tender anterior cervical lymphadenopathy, and absence of cough 4, 3.

Diphtheria-Specific Assessment

• Check vaccination status immediately—unvaccinated or incompletely vaccinated patients presenting with membranous tonsillitis should be presumed to have diphtheria until proven otherwise 2.
• Examine for the characteristic adherent gray-white pseudomembrane that bleeds when removal is attempted, along with "bull neck" appearance from cervical lymphadenopathy 1.
• Most cases occur in lower socioeconomic groups with inadequate vaccination coverage, particularly during November through January 1.

Empiric Antibiotic Management

First-Line Treatment for Confirmed GAS

• Prescribe penicillin V for 10 days as first-line therapy (dose: adults 500 mg PO twice daily; children 250 mg PO twice to three times daily based on weight) 4.
• Amoxicillin 500 mg every 12 hours (adults) or 25 mg/kg/day divided every 12 hours (children <40 kg) for 10 days is an acceptable alternative first-line treatment 4, 5.
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever, acute glomerulonephritis, and peritonsillar abscess 6, 4.

When to Use Amoxicillin-Clavulanate

• Switch to amoxicillin-clavulanate (875 mg/125 mg PO twice daily for adults; 45 mg/kg/day amoxicillin component divided twice daily for children) if the patient has received amoxicillin within the past 30 days or if polymicrobial infection with beta-lactamase-producing organisms is suspected 5, 7.
• Augmented aminopenicillins have gained utility with the increasing incidence of beta-lactamase-producing bacteria in acute tonsillitis 7.

Penicillin-Allergic Patients

• For non-severe penicillin allergy, use cefdinir 14 mg/kg/day once daily, cefuroxime 30 mg/kg/day divided twice daily, or cefpodoxime 10 mg/kg/day divided twice daily 4.
• Cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported (approximately 0.1%), making these agents safe for non-IgE-mediated allergies 8.

Diphtheria-Specific Management

When Diphtheria is Suspected

• Initiate diphtheria antitoxin immediately without waiting for culture confirmation if clinical suspicion is high (adherent membrane, unvaccinated status, "bull neck") 2.
• Administer erythromycin 500 mg PO four times daily or penicillin G 100,000-150,000 units/kg/day IV divided every 6 hours for 14 days to eradicate the organism 2.
• Isolate the patient immediately and notify public health authorities for contact tracing and prophylaxis 2.
• Emergency tracheostomy may be required if airway obstruction develops from membrane extension or cervical edema 1.

Supportive Care (All Patients)

• Provide acetaminophen or ibuprofen for pain and fever control at weight-based dosing 4.
• Ensure adequate hydration and educate caregivers about pain management and reassessment 4.
• Supportive care alone is sufficient for viral tonsillitis, which accounts for 70-95% of cases 3, 7.

Reassessment and Treatment Failure

• Reassess at 48-72 hours if symptoms worsen or fail to improve on initial antibiotic therapy 6.
• If amoxicillin or penicillin V fails, switch to amoxicillin-clavulanate to cover beta-lactamase-producing organisms 6, 7.
• Consider peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome (internal jugular vein thrombophlebitis) if fever persists beyond 72 hours despite appropriate antibiotics 6, 9.

Indications for Hospitalization

• Severe dysphagia preventing oral intake or hydration 9.
• Respiratory distress or stridor suggesting airway compromise 9, 1.
• Suspected diphtheria requiring antitoxin administration and airway monitoring 1, 2.
• Development of deep space neck infections (peritonsillar abscess, parapharyngeal abscess) 6, 9.

Tonsillectomy Consideration

• Watchful waiting is strongly recommended unless the patient meets Paradise criteria: ≥7 documented episodes in the past year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years 6, 4, 3.
• Each episode must be documented with temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 6, 4.
• Spontaneous improvement occurs in most patients, with control groups in randomized trials showing reduction to only 0.3-1.17 episodes per year without surgery 6, 4.

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming bacterial infection through RADT or culture, as 70-95% of tonsillitis is viral 4, 3.
• Do not use courses shorter than 10 days for GAS tonsillitis, as this increases treatment failure and rheumatic fever risk 6, 4.
• Do not dismiss diphtheria in the differential diagnosis—even in vaccinated populations, breakthrough cases occur, and mortality remains significant without antitoxin 1, 2.
• Avoid trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole for treatment failures due to substantial resistance 6.