Introduction Acute tonsillitis is a common clinical disease in the form of a feverish, self-limiting
infection. It is primarily of viral origin; the most common bacterial pathogens are
beta-hemolytic streptococci of Lancefield group A.
Case Report A 26-year-old patient presented with progressive sore throat, dysphagia, odynophagia
and fever. An oral penicillin therapy has had no effect. No stridor. In the clinical
examination there were kissing tonsils with smeary, whitish patches without an abscess
formation.
As oral ingestion was impossible and due to clinical suspicion of an Epstein-Barr
tonsillitis, the patient was admitted to the hospital. The serology seemed to confirm
the suspected diagnosis; it was positive for anti-VCA IgM/IgG and anti-EBNA-1 IgG
with negative anti-ZEBRA IgM.
Due to progressive dyspnea, tonsillectomy and adenotomy were performed. Postoperatively,
the patient had a 15 second asystole with prolonged syncope. A long-term ECG showed
a new, questionably virus-induced AV block type II Mobitz. An event recorder was implanted.
The histological examination revealed a florid tonsillitis with necrosis. The in-situ
hybridization was only able to find isolated EBV-positive cells. In the area of the
necrosis, cytoplasmic strongly stained cells for HSV-coded antigens could be detected.
The Herpes serology showed HSV-1/2-IgM/IgG, which verified the acute HSV infection.
Conclusion The clinical picture and course indicated an acute EBV infection. Only the histological
examination led to the diagnosis of a rare Herpes simplex tonsillitis. The case proves
the great importance of histological exploration even in the case of seemingly minor
illnesses, because only this made a personalised therapy possible.
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