Wednesday, November 2, 2016

PATCHED: When the tonsils shows a membrane

Hello everyone.

I'm back with a simple mnemonic to deal with a questionably common but very important issue: The Patch On The Tonsil.

The Tonsils (Palatine) represents the most important part of Waldeyer's ring.
(Just how your engagement ring signifies a ring of safety from other hotter people hitting on you, the Waldeyer's ring makes sure no organisms hit your body. )

Here is a simple mnemonic to remember the Differential Diagnosis of A Patch on The Tonsils:
Membrane Kissed In My eVery PATCH

I've tried to keep this in the order of importance, where:

Membranous Tonsillitis
Kissed In:
Infectious Mononucleosis or the Kissing Disease 
Malignancy of Tonsils / Leukemia

Vincent Angina
P: -

Apthous Ulcer
Corynebacterium diphtheriae
H: -

1. Membranous Tonsillits:
- Caused by Streptococci, Hib
- Generally a form of Acute Tonsillitis. 
- Exudates from the crypts begin to join and form a patch over the tonsil . 
- Membrane can be easily wiped away with a swab. 
- Whitish Membrane 

2. Infectious Mononucleosis:
- Caused by Epstein Barr Virus 
- Exudates appear similar to that in Membranous Tonsillits. 
- Generally in young adults. 
- Non responsive to Antibiotic Therapy. 
- Atypical Lymphocytosis and positive Paul Bunnel or Monospot test 
- Lymphadenopathy very prominent 

3. Malignancies:
- Local carcinoma Tonsil. 
- Leukemias - Due to immunocompromised state produced by lack of mature competent cells 

4. Vincent Angina:
- Caused by Anaerobes like Fusobacterium and Borrelia Vincent (mixed infection)
- Fever and Discomfort are lesser 
- Membrane easily dislodged. 
- Culture / Microscopy  would show Spirocheteal Borrelia and Anaerobic bacteria 

5. Agranulocytosis:
- Due to immunocompromised state 

6. Apthous Ulcer:
- (duh.)

7. Trauma:

8. Corynebacterium diphtheriae:
- Cause: Diphtheria.
- Membrane is extends beyond tonsils 
- Dirty grey in color 
- On removal it bleeds profusely 
- Albert's stain positive, Gram positive rods seen.
- Tellurite agar and Loeffer serum slope. Mnemonic: Tell-ur intern not to Loeffer around

- Candida affects anything with a mucosa on it. So tonsils are no different. 

So your Management should be: 
1. Analgesics 
2. H2O2 gargles 
3. Antibiotics empirically 
4. A. If Membrane suggests a diptheria - "Tell-ur intern not to Loeffer around." 
4. B. If not , and there isn't good response : 
    5. Get a CBC - To rule out Agranulocytosis and Leukemias. Lymphocytosis can also suggest EBV. 
    6. Get a smear to distinguish Atypical Lymphocytosis. (EBV NA or Paul Bunnel to clinch diagnosis)  
   7. Get a membrane swab and culture. 

Hope this post took you out of a rough patch :')
Let me know how you like these. 
Bye. :D 

~ A. P. Burkholderia


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