The patient and her story
The otherwise healthy 19-year-old woman had been treated with penicillin for a sore throat while testing negative for strep and COVID-19. However, as her symptoms intensified, she presented to the emergency department with a sore throat, difficulty swallowing, a hoarse voice, and a fever.
Results, evolution and treatment
Ultrasound revealed a peritonsillar abscess (PAA) on the left side. After aspiration of the abscess, her symptoms improved, and penicillin treatment was continued.
Two days later, the patient returned to the ENT clinic because her symptoms had worsened despite treatment. Examination once again revealed an abscess, which was incised and drained. Antibiotic therapy was switched to amoxicillin-clavulanic acid. The patient was also given methylprednisolone in progressive doses, leading to symptom improvement. Oral flora bacteria were identified in the culture.
However, four weeks later, the patient presented to the clinic again, where a peritonsillar abscess was diagnosed for the third time. After incision and drainage, she continued treatment with amoxicillin-clavulanic acid and methylprednisolone, unfortunately without success. While the symptoms initially decreased, they resurfaced two days later, and the woman now experienced dyspnea. Ultrasound and CT scans revealed a peritonsillar abscess causing slight narrowing of the airways. Bacterial culture subsequently identified the presence of Gardnerella vaginalis, a rod-shaped bacterium associated with the vaginal flora.
The explanation for this result came from the patient herself: she indicated that she had recently engaged in oral sex with a woman, whose partner had been in good health and had not experienced any abnormal vaginal discharge.
The peritonsillar abscess was incised and drained, and treatment with amoxicillin-clavulanic acid and steroids continued. The patient also received targeted metronidazole for the G. vaginalis infection. Six weeks later, a tonsillectomy was performed, and the patient recovered, becoming symptom-free.
Discussion
This patient had engaged in oral sex with a woman before the recurrence of the third peritonsillar abscess, and the predominant bacteria identified in the culture was G. vaginalis. The ENT specialists who treated her believe that G. vaginalis was transmitted from her partner and may have entered the peritonsillar space through an injury.
The peritonsillar abscess is a mixed aerobic-anaerobic infection, with group A streptococci being the dominant organisms. Diagnosis can often be established through clinical examination, while ultrasound and CT scans can provide more detailed findings. Patients are typically treated with antibiotics that target streptococci.
Therapeutic options include needle aspiration, incisional drainage, or tonsillectomy in cases of abscess formation. The latter is recommended in situations involving complications from the peritonsillar abscess or when alternative treatment methods have failed or in the case of recurrence.
Gardnerella is the predominant genus involved in bacterial vaginosis, which is the most common urogenital condition among women of childbearing age and is usually embedded in a biofilm matrix with bacterial species associated with the condition, according to the authors of a recent review article on bacterial vaginosis. However, Gardnerella alone is not the “infectious agent” of bacterial vaginosis, unlike Neisseria in gonorrhea.
Due to its high rate of treatment failure, bacterial vaginosis often presents a challenge in clinical practice. The authors suggest that women experiencing vulvovaginal disorders should still be evaluated for bacterial vaginosis, and treatment should only be initiated after a proper diagnosis has been made and confirmed by a physician. Treatment options include antibiotic therapy with oral or topical clindamycin or metronidazole, or the use of local antiseptics.
This case study was translated fromUnivadis.de using multiple editorial tools, including AI, in the process. The content was reviewed by the editorial staff before publication.
The Patient and Her Story
The otherwise healthy 19-year-old woman presented a perplexing medical case. Recently, she had been treated with penicillin for a sore throat, having tested negative for strep throat and Covid-19. However, as her symptoms began to escalate, she sought help at the emergency department due to a frustrating combination of sore throat, difficulty swallowing, a hoarse voice, and fever.
Results, Evolution, and Treatment
Diagnostic imaging via ultrasound revealed a peritonsillar abscess (PAA) on the left side. Following an aspiration of the abscess, her symptoms initially diminished, prompting the continuation of penicillin treatment.
To the medical team’s concern, two days later, the patient returned to the ENT clinic as her symptoms had unfortunately worsened despite the course of antibiotics. A thorough examination led to the diagnosis of an abscess once more, requiring incisional drainage. As a result of the recurring nature of her condition, antibiotic therapy was modified to amoxicillin-clavulanic acid. Additionally, she was prescribed methylprednisolone in progressive doses, leading to an improvement in her symptoms. Subsequent cultures identified oral flora germs in the sample.
Despite these efforts, four weeks later, the patient made another visit to the clinic, where a third diagnosis of peritonsillar abscess was confirmed. After another round of incision and drainage, treatment with amoxicillin-clavulanic acid and methylprednisolone continued, yet the outcomes were lackluster. While the symptoms temporarily subside, they returned with a vengeance just two days later, alongside the alarming development of dyspnea. Further imaging studies, including ultrasound and CT scans, indicated a PAA causing slight airway narrowing. Notably, a bacterial culture revealed the presence of Gardnerella vaginalis, a rod-shaped bacillus commonly associated with the vaginal flora.
The patient herself provided crucial context for this finding. She disclosed having engaged in oral sex with a female partner; her partner had presented no signs of abnormal vaginal health.
The management of the peritonsillar abscess involved another surgical intervention for incision and drainage. The treatment regimen was reiterated with amoxicillin-clavulanic acid and methylprednisolone, supplemented with targeted metronidazole for G. vaginalis. Six weeks following this strategy, a tonsillectomy was performed, leading to a complete recovery with no subsequent symptoms.
Discussion
This case highlights the complexity involved in diagnosing and treating peritonsillar abscesses, especially in the context of potential non-traditional bacterial sources. The correlation between the patient’s sexual activity with a female partner and the subsequent recurrence of the abscess, with G. vaginalis dominating the culture, suggests a unique case of bacterial transmission. The ENT specialists involved theorized that the bacteria could have entered the peritonsillar space via a micro-wound.
Understanding Peritonsillar Abscesses
A peritonsillar abscess arises as a result of mixed aerobic and anaerobic infections, primarily driven by group A streptococci. Prompt diagnosis often relies on clinical evaluation, while imaging techniques such as ultrasound and CT scans can provide more comprehensive insights.
Common Symptoms of Peritonsillar Abscess
- Sore throat
- Difficulty swallowing
- Hoarseness of voice
- Fever
- Swelling of the tonsils
- Trismus (difficulty opening the mouth)
- Dyspnea in severe cases
Treatment Options for Peritonsillar Abscess
Effective management of peritonsillar abscess usually necessitates a multi-faceted approach:
- Antibiotic therapy: Commonly prescribed antibiotics include penicillin and alternative broad-spectrum agents like amoxicillin-clavulanic acid.
- Surgical intervention: Options include needle aspiration, incisional drainage, or tonsillectomy, particularly in cases with severe symptoms or recurrent abscesses.
- Supportive care: Patients may benefit from corticosteroids to reduce inflammation and facilitate recovery.
Gardnerella and Its Clinical Implications
Gardnerella vaginalis is primarily associated with bacterial vaginosis, which commonly affects women in their reproductive years. It is important to understand that Gardnerella does not act as the sole infectious agent; rather, it exists within a biofilm alongside various bacteria that collectively contribute to vaginosis.
Challenges in Treating Bacterial Vaginosis
Managing bacterial vaginosis can often prove challenging due to its high treatment failure rates. Health professionals emphasize the importance of accurate diagnosis and tailored treatment, which may include:
- Oral or topical antibiotics such as clindamycin or metronidazole.
- Local antiseptic preparations may also be considered.
Case Study Insight
This case study presents a unique perspective on the potential transmission of vaginal flora to the oropharyngeal environment, emphasizing the necessity of a thorough sexual history in patients presenting with recurrent throat infections. Understanding the links between different types of infections can lead to more effective treatment strategies.
Conclusion
In summary, the case of the 19-year-old woman illustrates the complexity of diagnosing and treating peritonsillar abscesses. The intersection of bacterial transmission related to sexual activity highlights the need for increased awareness among healthcare professionals regarding the diverse routes through which infections may occur.
This case study was translated from Univadis.de using multiple editorial tools, including AI, in the process. The content was reviewed by the editorial staff before publication.