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Mazur et al. BMC Infectious Diseases (2015) 15:50DOI 10.1186/s12879-015-0780-8CASE REPORTOpen AccessConcurrent peritonsillar abscess andpoststreptococcal reactive arthritis complicatingacute streptococcal tonsillitis in a young healthyadult: a case reportElżbieta Mazur1*, Ewa Czerwińska2, Aneta Grochowalska3 and Maria Kozioł-Montewka1AbstractBackground: Streptococcus pyogenes is responsible for 5-15% and 20-30% of acute pharyngitis/tonsillitis in adultsand children, respectively. It not only causes acute illness but also can give rise to local suppurative complicationssuch as peritonsillar abscess as well as trigger the postinfectious syndromes of glomerulonephritis, acute rheumaticfever and poststreptococcal reactive arthritis. Here, we report a case of a young healthy adult in whom bothperitonsillar abscess and poststreptococcal reactive arthritis developed as a complication of acute streptococcaltonsillitis. To the best of our knowledge, such a coincidence of poststreptococcal sequelae has not beenreported previously.Case presentation: A 32-year-old previously healthy woman was diagnosed with acute tonsillitis by her familydoctor and treated empirically with amoxicillin/clavulanic acid (875/125 mg) twice daily for 5 days. Four days aftercompleting antibiotic therapy, peritonsillar abscess of left tonsil developed. Needle aspiration followed by incisionand drainage were performed by otolaryngologist at the Emergency Department. Next, the patient was dischargedhome on a 10-day course of cefuroxime and metronidazole. The symptoms of peritonsillar abscess were subsidingduring treatment, however on the last day of antibiotic therapy, swelling and pain of the left ankle appeared.Five days later the patient was consulted by rheumatologist. Cultures of throat swabs and abscess aspiratecollected 2 weeks before revealed the presence of Streptococcus pyogenes. Antistreptolysin O (ASO) titer wasevaluated and proved to be 412 IU/ml (normal 0–200 IU/ml). The level of C-reactive protein was 13,0 mg/L(normal 5,0 mg/L). There was no known cardiac involvement. Poststreptococcal reactive arthritis was diagnosed.Left ankle arthralgia persisted for about 5–6 weeks. Six months after the presentation at the Emergency Department,the patient was well, with ASO titer reaching 262 IU/ml.Conclusions: Clinicians should be aware that appropriate choice of antibiotic, proper dose as well as duration oftherapy of acute GAS pharyngitis/tonsillitis are crucial to prevent poststreptococcal sequelae.Keywords: Streptococcus pyogenes, Tonsillitis, Peritonsillar abscess, Poststreptococcal reactive arthritis, Antibiotic therapy* Correspondence: [email protected] Microbiology Department, Medical University of Lublin, ul. Chodźki1, 20-093 Lublin, PolandFull list of author information is available at the end of the article 2015 Mazur et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver ) applies to the data made available in this article,unless otherwise stated.

Mazur et al. BMC Infectious Diseases (2015) 15:50Page 2 of 5BackgroundStreptococcus pyogenes (group A streptococcus, GAS)is responsible for 5 to 15% and 20 to 30% of acutepharyngitis/tonsillitis in adults and children, respectively.It not only causes acute illness but also can give rise tolocal suppurative complications such as peritonsillar abscess (PTA) as well as trigger the postinfectious syndromesof glomerulonephritis, acute rheumatic fever (ARF) andpoststreptococcal reactive arthritis (PSRA) [1-3]. PTA, defined as a collection of pus located between the tonsillarcapsule and the pharyngeal constrictor muscle, occursmainly in young adults [4,5]. PSRA is defined as arthritisassociated with proven streptococcal infection but not fulfilling the modified Jones criteria for the diagnosis of acuterheumatic fever [2,3]. Here, we report a case of a younghealthy adult in whom both, PTA and PSRA, developed asa complication of acute streptococcal tonsillitis. To thebest of our knowledge, such a coincidence of poststreptococcal sequelae has not been reported previously.Case presentationA 32-year-old woman was diagnosed with acute tonsillitis by her family doctor. Microbiological examinationwas not performed at that time. Amoxicillin/clavulanicacid 875/125 mg twice daily for 5 days was prescribedempirically. The symptoms of tonsillitis resolved withinfive-day treatment, however, four days after completingthe course of antibiotic therapy, sore throat, more prominent on the left side, reappeared. Two days later the patientpresented to the Emergency Department with a two-dayhistory of worsening sore throat, painful swallowing andfever. The patient was previously well, with no history ofchronic diseases, recurrent tonsillitis or previous peritonsillar abscess. Seven months previously she gave birthto her second child and was still breastfeeding thebaby. She denied smoking. On physical examination hertemperature was 38 C, pulse rate: 80 beats/min, respiratory rate: 22 breaths/min and blood pressure: 120/80 mm Hg. Examination of the oral cavity and oropharynxshowed enlarged and inflamed left tonsil as well as congested and bulging soft palate on the left side withcontralateral displacement of the uvula. Both tonsilswere covered with whitish exudate. No dental caries wasnoted. There was also bilateral, moderately tender submandibular lymphadenopathy. The remainder of physicalexamination was unremarkable. Blood tests results areshown in Table 1. Separate swabs were obtained from thesurfaces of both tonsils. Next, under local anesthesia, diagnostic needle aspiration of left tonsil was performed byotolaryngologist, during which scanty amount of pus wasobtained. This initial procedure was followed by incisionand drainage. Tonsil swabs and abscess aspirate were sentto laboratory for microbiological examination. The patientrefused hospitalization at the Otolaryngology Department,thus was discharged home on a 10-day course of cefuroxime (500 mg twice daily) and metronidazole (500 mg 3times daily) with recommendation to discontinue breastfeeding for the duration of the antibiotic therapy and topresent at follow-up visit to Otolaryngology Clinic aftercompleting antibiotic therapy. The symptoms of peritonsillar abscess as well as fever were subsiding steadily during treatment, however on the last day of antibiotictherapy, swelling and pain of the left ankle appeared, thusthe patient presented to her family doctor. Upon presentation she was afebrile and had marked oedema and pain ofher left ankle. Her heart rate was 72 beats/min, she didnot have an appreciable cardiac murmur. Her chest wasclear to auscultation. Antibiotic therapy with cefuroximeTable 1 Summary of clinical findings and blood tests over timeTimelineClinical findingsBlood tests resultsDay 1: presentation to the family doctorAcute tonsillitisNot performedDay 11: presentation to the Emergency DepartmentLeft side peritonsillar abscessLeukocytosis: 15 270/mm3 Granulocytes: 79.7%Lymphocytes: 15.9%Monocytes: 2.8%Hemoglobin: 13.0 g/dl Hematocrit: 38.9%Platelet count: 329 000/mm3CRP: 131.0 mg/L (normal 5.0 mg/L)Day 20: 2nd presentation to the family doctorLeft ankle arthritisNot performedDay 25: follow-up visit to the Otolaryngology Departmentand the rheumatologist consultationLeft ankle arthralgiaASO: 412 IU/ml (normal 0–200 IU/ml)Day 40: 1st follow up to the rheumatologistLeft ankle arthralgiaASO: 503 IU/mlDay 100: 2nd follow up to the rheumatologistHealthyASO: 396 IU/mlDay 180: 3rd follow up to the rheumatologistHealthyASO: 262 IU/mlCRP: C-reactive protein; ASO: antistreptolysin titer.CRP: 13.0 mg/L

Mazur et al. BMC Infectious Diseases (2015) 15:50(500 mg once daily) for next 5 days was prescribed, as wellas pain relief medication with paracetamol. After completing antibiotic therapy the patient presented at follow-upvisit to Otolaryngology Clinic. She was afebrile, with normal vital signs. Examination of oropharynx showed resolution of both, congestion and oedema of left tonsil andsoft palate. There was no exudate on the tonsils. Culturesof throat swabs and abscess aspirate collected 2 weeks before revealed the presence of Streptococcus pyogenes in allthree materials. According to the patient report, left ankleswelling with which she presented to her family doctor, resolved within 4 days. Upon presentation the patient onlyhad moderate pain in the joint. She was consulted byrheumatologist. Her heart rate was 70 beats/min. She didnot have a regurgitant murmur. Her chest was clear toauscultation. Antistreptolysin O (ASO) titer was evaluatedand proved to be 412 IU/ml (normal 0–200 IU/ml). Thelevel of C-reactive protein was 13,0 mg/L. Control throatswabs were collected for culture, which revealed normaloropharynx flora. The patient was recommended to continue pain relief medication with paracetamol and presentat follow-up visit to Rheumatology Clinic after 2 weeks.Her only complaint was persisting slight pain in left anklejoint. The results of physical examination were analogousto those observed at previous follow-up. ASO titer was503 IU/ml. Control throat swabs were collected and culture yielded normal flora. The patient was recommendedto present at follow-up visit at Rheumatology Clinic after2 months. At that time, she was well. Ankle pain, according to the patient report, disappeared shortly after lastvisit. The results of physical examination were analogousto those observed previously. ASO titer was 396 IU/ml.Six months after the presentation at Emergency Department, the patient was well, with ASO titer reaching262 IU/ml. Table 1 summarizes the chronology of clinicalfindings and blood tests results.Bacteriology findingsCultures of PTA aspirate revealed Streptococcus pyogenesas a predominant species as well as Prevotella oralis andHaemophilus parainfluenzae. Tonsil swabs, collected atthe time the patient presented with PTA, yielded copious growth of Streptococcus pyogenes as well as normalthroat flora, namely Streptococcus viridians, Neisseria spp,and Haemophilus parainfluenzae. Two control throatswabs revealed only normal oropharynx flora. Bacterial species were identified with the use of routine microbiologicalmethods, drug susceptibility of S. pyogenes was assessedusing Vitek 2 Compact (bioMérieux). Antimicrobial susceptibility results were interpreted according to the EuropeanCommittee on Antimicrobial Susceptibility Testing recommendations (EUCAST 2013, version 3.1) [6]. Streptococcuspyogenes strains isolated from tonsil swabs and abscess aspirate demonstrated identical susceptibility patterns. TheyPage 3 of 5were resistant to erythromycin, clindamycin, tetracyclineand fully susceptible to all other antibiotics tested. MLSiphenotype (inducible coresistance to macrolide, lincosamide and streptogramine) was detected with the use ofdouble-disc diffusion testing [7].DiscussionGAS pharyngitis is a self-limiting disease in most cases,however, it can cause suppurative and nonsuppurativecomplications [1,2]. In our patient both, peritonsillar abscess and poststreptococcal reactive arthritis occurred asa complication of acute GAS tonsillitis. Although microbiological examination was not performed at the timethe patient presented with tonsillitis, the reappearance ofsore throat within 4 days after completing a 5-day antibiotic therapy with amoxicillin/clavulanic acid and thepresence of GAS in throat swab cultures at the time shepresented with PTA, strongly suggest GAS aetiology ofantecedent tonsillitis. Moreover, the isolation of GASstrains with identical susceptibility patterns from both,throat swabs and abscess aspirate, leaves no doubt thatGAS strain that caused tonsillitis participated in the development of PTA. From the majority of PTA aspiratespolymicrobial mixture of aerobic and anaerobic bacteriais recovered, however, GAS along with Fusobacteriumnecrophorum are commonly regarded to be the primarypathogens [4,5]. In our patient three bacterial specieswere detected in abscess aspirate: GAS, Prevotella oralis,and H. parainfluenzae. There are no uniform recommendations regarding PTA antibiotic therapy, thus treatment options vary greatly between clinicians and arebased mainly on their preferences [4,8,9]. In most casesantibiotics of choice include penicillin combined withmetronidazole, amoxicillin with clavulanic acid, clindamycin, cefuroxime, or metronidazole [8-10]. In our department cefuroxime combined with metronidazole isadministered as empiric antimicrobial therapy in mostcases, our patient was treated with these drugs as well.PSRA is defined as arthritis associated with provenstreptococcal infection but not fulfilling the modifiedJones criteria for the diagnosis of acute rheumatic fever(ARF). It is still not clear whether this entity representsa distinct syndrome or is a manifestation of ARF [2,3].ARF has now become rare in developed countries. Its incidence in Western Europe is currently less than 1 caseper 100 000 population, whereas PSRA is relatively morefrequent with the annual incidence of approximately 2cases per 100 000 people [11]. There is a mean intervalof 14 days between the onset of GAS pharyngitis symptoms and the occurrence of PSRA [3]. Age distributionappears to be bimodal, with two incidence peaks, at ages8–14 and 21–37 years, respectively [3]. Joint involvement is typically non-migratory and affects large joints,particularly those of lower limbs. Knee and ankle joints

Mazur et al. BMC Infectious Diseases (2015) 15:50are regularly involved, although small joints and axial involvement occurs as well. Mono-, oligo- and polyarthritis are equally represented. Unlike the self-limiting andexquisitely responsive to salicylates arthritis of ARF,PSRA responds relatively poorly to salicylates and nonsteroid anti-inflammatory drugs. Carditis is a rare event.The disease resolves within weeks [3,11,12]. Discrimination between ARF and PSRA is ambiguous due to thelack of generally accepted set of criteria for the diagnosisof PSRA [11]. In our patient non-migratory monoarthritis, localized in the left ankle, without fever or knowncardiac involvement occurred approximately 20 daysafter the onset of tonsillitis while the patient was still onantibiotic therapy due to PTA. Although joint oedema resolved within 4 days, arthralgia, moderately responsive tononsteroid anti-inflammatory drugs, persisted for about5–6 weeks. Antecedent GAS throat infection was confirmed by cultures as well as serologically. However, themodified Jones criteria were not fulfilled, thus PSRA wasdiagnosed. Similarly to what was noted by Jansen et al.[13], clinical findings of PSRA in our patient had subsidedbefore ASO titre reached its maximum value. At present,there are no evidence-based guidelines whether patientswith PSRA, similarly to those with ARF, should receivelong-term antibiotic prophylaxis [11]. Recent data indicateno increased risk of valvular heart disease in adults withPSRA [14]. Accordingly, our patient did not receive secondary antibiotic prophylaxis.Some European guidelines, among them British, Scottish,Dutch and Belgian, consider GAS pharyngitis to be amild, self-limiting disease that does not require a specific diagnosis or antimicrobial treatment except in highrisk patients, such as those with a history of valvular heartdisease or acute rheumatic fever, immunosuppressed orseverely ill [15-18]. Recently issued recommendations ofEuropean Society of Clinical Microbiology and InfectiousDiseases represent similar approach [19]. However, theremaining European and North American guidelines recommend that all cases of acute streptococcal pharyngitis/tonsillitis should be appropriately treated to prevent both,suppurative and nonsuppurative poststreptococcal complications [20]. According to Polish recommendations,phenoxymethyl penicillin, 2–3 million units twice daily for10 days, is currently antibiotic therapy of choice for GASpharyngitis. Second and third-line drugs include: first generation cephalosporin in patients with penicillin allergywho do not have immediate hypersensitivity to betalactam antibiotics or macrolides (erythromycin, azithromycin, clarithromycin) in those with hypersensitivity tobeta-lactam antibiotics. Azithromycin is the only drugthat is given in a 5-day course as opposed to a 10-daycourse for all the other antibiotics [21]. Currently, AmericanHeart Association/American Academy of Pediatrics andInfectious Diseases Society of America recommendPage 4 of 5amoxicillin once or twice daily for 10 days as alternativefirst-line therapy, since in comparative clinical trials oncedaily amoxicillin (50 mg/kg, to a maximum of 1000 mg)for 10 days has been shown to be effective for GAS pharyngitis [2,22]. However, the treatment of tonsillitis in ourpatient did not comply the recommendations, particularlywith respect to the duration of therapy. Five-day treatmentwith amoxicillin/clavulanic acid resulted in the lack ofGAS eradication, which in turn caused both PTA andPSRA.ConclusionIn summary, to the best of the authors’ knowledge, thisis the first published account of the coincidence of bothPTA and PSRA, complicating acute GAS tonsillitis in ayoung healthy adult. Moreover, the occurrence of bothcomplications might have an association with impropermanagement of acute streptococcal tonsillitis. Cliniciansshould be aware that appropriate choice of antibiotic,proper dose as well as duration of therapy of acute GASpharyngitis/tonsillitis are crucial to prevent poststreptococcal sequelae.ConsentWritten informed consent was obtained from the patientfor publication of this case report. A copy of the writtenconsent is available for review by the Editor of this journal.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsEM conceived the idea of the case description and coordinated drafting themanuscript. EC was responsible for the patient’s management and collectedall significant clinical information. AG, EM and MKM participated in thebacteriologic studies. All authors participated in drafting and revising themanuscript. All authors read and approved its final version.Authors’ informationEM, MKM: Medical Microbiology Department, Medical University of Lublin,Poland.EC: Department of Otolaryngology, Regional Specialist Hospital in Radom,Poland.AG: Microbiological Laboratory at the Regional Specialist Hospital in Radom,Poland.Author details1Medical Microbiology Department, Medical University of Lublin, ul. Chodźki1, 20-093 Lublin, Poland. 2Department of Otolaryngology, Regional SpecialistHospital in Radom, ul. Aleksandrowicza 5, 26-617 Radom, Poland.3Microbiological Laboratory at the Regional Specialist Hospital in Radom, ul.Aleksandrowicza 5, 26-617 Radom, Poland.Received: 15 June 2014 Accepted: 23 January 2015References1. Wessels MR. Clinical practice: streptococcal pharyngitis. N Engl J Med.2011;364:648–55.2. 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completing antibiotic therapy, peritonsillar abscess of left tonsil developed. Needle aspiration followed by incision and drainage were performed by otolaryngologist at the Emergency Department. Next, the patient was discharged home on a 10-day course of cefuroxime and metronidazole. The symptoms