Case Report
A recurrent tonsillitis
Marie Fourage, Christophe Bourguignat, Bruno Fermond, Pierre Delobel
Lancet 2013; 381: 266 In March, 2012, a 38-year-old man presented to us with a
CIBAM, SELAS Novescia, 3-week history of recurrent episodes of fever, bilateral
Saint Alban, France tonsillitis with tonsillar exudates, and enlarged cervical
(M Fourage PharmD); Cabinet
nodes. He had been given amoxicillin (1 g twice a day) for
mdical, Saint Alban, France,
(C Bourguignat MD, 6 days but relapsed 3 days after completion of treatment.
B Fermond MD); and Centre He was given cefpodoxim (200 mg twice a day) for 5 days
Hospitalier Universitaire de but relapsed 1 day later. A rapid test for group A
Toulouse, Hpital Purpan,
streptococcus, and serological tests for HIV and Epstein-
Service des Maladies
Infectieuses et Tropicales, Barr virus (EBV), were negative. White blood cell count
Toulouse, France (16 g/L, 88% neutrophils) and C-reactive protein (121 mg/L)
(P Delobel PhD) suggested bacterial infection. Tonsillitis due to
Correspondence to: Fusobacterium necrophorum was suspected. Metronidazole
Dr Marie Fourage, CIBAM,
(500 mg orally 3 times a day for 10 days) was started and
32 Avenue de Villemur,
31140 Saint Alban our patient recovered rapidly.
mariefourage@gmail.com The microbiological diagnosis (see appendix) conrmed
tonsillitis due to F necrophorum subsp fundiliforme, which
See Online for appendix is characteristic of human infections.1,2 The throat smear
showed Gram-negative pleomorphic bacteria with
clusters of cocci and coccobacilli (gure A), suggestive of
this subspecies.1,2 This organism should not be confused
with the spindle-shaped bacilli F nucleatum, which is
found in the fusospirochaetal complex, the agent of the
ulceronecrotic Plaut-Vincent angina. Moreover, the gram
smear displayed throat cells covered, and most likely
invaded, by these bacteria (gure B). Previous in-vitro
evidence of intracellular invasion and replication of
F necrophorum supports this nding.3 In September, 2012,
at last follow up, there had been no recurrence.
Our patients case draws attention to an alternative
pathogen for tonsillitis. F necrophorum is probably often
underdiagnosed because it is not sought in microbiological
tests in routine throat culture. The clinical presentation
and natural history of tonsillitis due to F necrophorum are
not well known. F necrophorum is the well known agent of
Lemierres syndrome,4 a septic thrombophlebitis of the
internal jugular vein leading to septicaemia and septic
pulmonary emboli. However, its role in common tonsillitis
is also underscored by its strong association with
A B
Figure: Gram smear of the throat swab (x1000)
(A) Showing saprophytic polymorphic ora, including Gram-positive ora replaced by a heavy load of
Gram-negative clusters of cocci and bipolar-stained coccobacilli, embedded in cellular material. (B) Many throat
cells are covered and probably invaded by the Gram-negative pleomorphic bacteria, showing clue-cell-like throat
cells that are similar to those seen with vaginosis.
266
peritonsillar abscess (up to 60%),5 growing sometimes as a
pure culture. In our patient, the eectiveness of metro-
nidazole supports a pathogenic role of F necrophorum since
metronidazole is not active against aerobic pathogens.
Epidemiological studies indicate that F necrophorum might
be a more common cause of acute and recurrent tonsillitis,1
which challenges the well established dichotomy of
streptococcal and viral tonsillitis. F necrophorum should be
suspected in acute bacterial tonsillitis when a rapid test for
group A Streptococcus is negative. Main dierential
diagnoses include group C or G Streptococcus dysgalactiae,
or rare false negative tests for group A S pyogenes.
Amoxicillin remains the drug of choice for empirical
treatment because beta-lactamase production is rare
in F necrophorum.2 Macrolides are inactive against
F necrophorum. There are no consensus guidelines on
management of recurrent tonsillitis. Clindamycin is an
alternative to metronidazole, and has an extended
spectrum of action against streptococci. Both reach high
intracellular concentrations. Intracellular reservoirs of
bacteria are probably a key mechanism for explaining
relapses after beta-lactam treatment despite in-vitro
susceptibility, and should be targeted rather than extending
the spectrum of antibiotherapy to beta-lactamase pro-
ducers. Since 1936,4 tonsillitis due to F necrophorum has
remained a mystery. The pathogen might be overlooked as
a prevalent missing link between acute tonsillitis, recurrent
tonsillitis, peritonsillar abscesses, and the life-threatening
Lemierres syndrome. Our case shows that in cases of
acute tonsillitis for which a test for group A streptococcus
is negative, high-level inammatory markers should be
a red ag for suspecting bacterial tonsillitis, notably
F necrophorum, to prevent suppurative complications.
Contributors
MF, CB, BF looked after the patient, MF did the diagnostic testing, and
MF, PD wrote the report. Written consent to publication was obtained.
Acknowledgments
Pr Alexis Valentin and Pr Antoine Berry (Laboratoire Parasitologie-
Mycologie, CHU Rangueil, Toulouse, France) for photos. The French
National Centre for anaerobic bacteria (Institut Pasteur, Paris, France) for
conrming the identication and performing susceptibility testing.
References
1 Riordan T. Human infection with Fusobacterium necrophorum
(Necrobacillosis), with a focus on Lemierres syndrome.
Clin Microbiol Rev 2007; 20: 62259.
2 Jensen A, Hagelskjaer Kristensen L, Nielsen H, Prag J. Minimum
requirements for a rapid and reliable routine identication and
antibiogram of Fusobacterium necrophorum.
Eur J Clin Microbiol Infect Dis 2008; 27: 55763.
3 Gursoy UK, Knnen E, Uitto VJ. Intracellular replication of
fusobacteria requires new actin lament formation of epithelial
cells. APMIS 2008; 116: 106370.
4 Lemierre A. On certain septicaemias due to anaerobic organisms.
Lancet 1936; 227: 70103.
5 Klug TE, Henriksen JJ, Fuursted K, Ovesen T. Signicant pathogens
in peritonsillar abscesses. Eur J Clin Microbiol Infect Dis 2011;
30: 61927.
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