15 year old female Bilateral swelling of tonsil
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A 15-year-old female with bilateral tonsillar swelling - the top differential is acute tonsillitis (bacterial or viral), with infectious mononucleosis (EBV) being a key concern at this age. Let me search the medical library for comprehensive coverage.
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Good - found multiple sources. Let me read from Bailey & Love (surgery), Scott-Brown (ENT), and also search for infectious mononucleosis in parallel.
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Good content found. Now let me search for EBV/glandular fever and also get the Centor/McIsaac scoring criteria and tonsillectomy indications.
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Bilateral Tonsillar Swelling - 15-Year-Old Female
Clinical Overview
Bilateral tonsillar swelling in a 15-year-old female has a wide differential, with acute tonsillitis (bacterial or viral) being the most common cause and infectious mononucleosis (EBV/glandular fever) being the most important diagnosis not to miss at this age.
Differential Diagnosis
| Condition | Key Features |
|---|---|
| Acute bacterial tonsillitis (Group A beta-haem. Strep - GABHS) | Fever, sore throat, dysphagia, exudates, cervical lymphadenopathy |
| Viral tonsillitis (Adenovirus, rhinovirus, etc.) | Milder, associated URTI symptoms |
| Infectious mononucleosis (EBV) | Adolescent age group, bilateral tonsil swelling, grey/white exudates, posterior cervical lymphadenopathy, splenomegaly, hepatomegaly |
| Peritonsillar abscess (Quinsy) | Usually unilateral, trismus, uvular deviation - in bilateral swelling, less likely |
| Tonsillar lymphoma | Painless, progressive, asymmetric enlargement, systemic "B symptoms" (night sweats, weight loss) |
| Diphtheria | Grey membrane, "bull neck," stridor - now rare with vaccination |
Key point at this age: EBV glandular fever can closely mimic bacterial tonsillitis and must be actively excluded.
History - Key Questions
- Duration and onset of sore throat
- Fever, malaise, fatigue (EBV causes pronounced systemic illness)
- Dysphagia / odynophagia
- Neck swelling (anterior vs posterior cervical nodes)
- Recent upper respiratory tract infection
- Contact with ill individuals
- Rash (especially if amoxicillin has been given - maculopapular rash = EBV)
- Vaccination status (diphtheria)
- Recurrence history (suggests chronic/recurrent tonsillitis)
- Snoring / sleep disturbance (tonsillar hypertrophy)
Examination
Oropharynx
- Size of tonsils (grade I-IV)
- Erythema, exudates (white/yellow pustules = follicular tonsillitis)
- Grey membrane (diphtheria)
- Uvula position (midline = bilateral disease; displaced = quinsy on one side)
- Trismus (suggests peritonsillar abscess)
Lymph nodes
- Anterior cervical (jugulodigastric) - typical of bacterial tonsillitis
- Posterior cervical + axillary + inguinal - hallmark of EBV
Abdomen
- Hepatosplenomegaly (EBV - risk of splenic rupture)
Skin
- Maculopapular rash after ampicillin/amoxicillin = strongly suggests EBV
- Palatal petechiae (EBV or strep)
Investigations
| Test | Purpose |
|---|---|
| Throat swab (MC&S) | Identify GABHS and antibiotic sensitivities |
| Monospot test / Paul-Bunnell test | Heterophile antibodies for EBV (may be negative early in illness) |
| EBV-specific antibodies (IgM anti-VCA) | More sensitive than monospot, confirms EBV |
| FBC | Atypical lymphocytes (>10% suggests EBV); neutrophilia suggests bacterial |
| LFTs | Transaminase elevation in EBV |
| CRP / ESR | Inflammatory markers |
| ASO titre | If rheumatic fever/post-strep sequelae suspected |
Management
Acute Tonsillitis (Bacterial)
Symptomatic:
- Paracetamol ± ibuprofen for analgesia and fever
- Saline gargles
- Adequate hydration
Antibiotic therapy:
- Penicillin V (phenoxymethylpenicillin) - first-line, 10-day course
- Benzylpenicillin IV if unable to swallow orally
- Avoid ampicillin/amoxicillin - causes a widespread maculopapular rash in EBV patients (even before the diagnosis is confirmed)
- Erythromycin if penicillin-allergic
- Antibiotics shorten illness and reduce risk of complications; if no improvement in 48-72 hours, reassess and start/escalate antibiotics
Corticosteroids:
- Oral or IM dexamethasone - evidence supports symptomatic pain relief in addition to antibiotics, especially in severe cases
If EBV Confirmed
- Supportive management (rest, analgesia, fluids)
- Avoid contact sports / strenuous activity for at least 4-6 weeks due to risk of splenic rupture
- No amoxicillin or ampicillin
- Steroids used for severe airway compromise or severe thrombocytopaenia
Complications
Local:
- Peritonsillar abscess (quinsy) - pus lateral to tonsil, needs drainage
- Parapharyngeal/retropharyngeal abscess
- Airway obstruction (massive hypertrophy)
Systemic (post-streptococcal):
- Rheumatic fever - carditis, arthritis (prevented by adequate penicillin treatment)
- Post-streptococcal glomerulonephritis
- Septicaemia
EBV-specific:
- Splenic rupture
- Haematological complications
- Rare: meningitis, myocarditis
Indications for Tonsillectomy
Absolute:
- Sleep apnoea / chronic upper airway obstruction / cor pulmonale
- Suspected tonsillar malignancy
Relative (documented recurrence required):
- Recurrent acute tonsillitis (≥5-7 episodes/year, or ≥5 episodes for 2 consecutive years)
- Chronic tonsillitis
- Previous peritonsillar abscess (quinsy)
- Tonsillar asymmetry (to exclude lymphoma)
- Tonsillitis causing febrile convulsions
- Diphtheria carrier
- Systemic disease caused by beta-haemolytic Streptococcus (nephritis, rheumatic fever)
Procedure is ideally done when tonsils are not acutely infected.
When to Admit / Escalate
- Inability to swallow / drooling
- Stridor / airway compromise
- Suspected quinsy (needs drainage)
- Signs of sepsis
- Suspected EBV with severe airway compromise or haematological complications
Sources: Bailey and Love's Short Practice of Surgery 28th Ed., p. 807-808 | Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 2
Final real world prescription
Asking for Preferences
What is the clinical picture right now? · EBV / mononucleosis status? · Prescription setting?
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acute tonsillitis prescription penicillin V dose adolescent 2024 guidelines
Here is a real-world outpatient prescription for a 15-year-old female with moderate acute tonsillitis (exudates + fever + dysphagia), EBV not yet excluded:
Rx - Acute Tonsillitis (Outpatient)
Patient: 15-year-old female | Weight: ~50 kg (adjust if known)
⚠️ Critical Rule Before Writing
Do NOT prescribe amoxicillin or ampicillin until EBV is excluded. If EBV is the cause, these trigger a florid maculopapular rash. Use penicillin V or azithromycin only.
Prescription
1. Antibiotic
Tab. Phenoxymethylpenicillin (Penicillin V) 500 mg
- 1 tab twice daily (BD) × 10 days
- Take on an empty stomach (30 min before food)
OR if compliance with 10-day course is a concern:
Tab. Azithromycin 500 mg
- 1 tab once daily × 5 days
- (Penicillin-allergic patients or if compliance is the issue)
2. Analgesia / Antipyretic
Tab. Paracetamol 500 mg
- 1-2 tabs every 6 hours as needed (max 4g/day)
- For pain and fever
Tab. Ibuprofen 400 mg
- 1 tab every 8 hours after food × 5 days
- Excellent anti-inflammatory for odynophagia; avoid if GI issues
3. Corticosteroid (for moderate dysphagia + pain - evidence-supported)
Tab. Dexamethasone 8 mg - single dose stat OR
Tab. Prednisolone 40 mg once daily × 3 days
- Significantly reduces pain, swelling, and time to resolution
- Recommended in moderate-severe tonsillitis alongside antibiotics
4. Local Relief
Benzydamine (Difflam) 0.15% oropharyngeal spray
- 4-8 sprays every 3 hours as needed
- Directly reduces throat pain and inflammation
Warm saline gargles
- Half teaspoon salt in warm water, gargle × 30 sec, 4-5 times daily
5. Investigations to Send Today
| Test | Reason |
|---|---|
| Throat swab MC&S | Confirm GABHS, guide antibiotics |
| Monospot / Paul-Bunnell | EBV screen (if negative and high suspicion, send EBV IgM VCA) |
| FBC | Atypical lymphocytes (EBV), WBC |
| CRP | Inflammatory marker |
Advice to Patient / Parent
- Complete the full 10-day antibiotic course even if feeling better
- Do not take amoxicillin/augmentin (from another doctor or pharmacy) until EBV result is back
- Return immediately if:
- Difficulty breathing or stridor
- Unable to swallow fluids / drooling
- Trismus (jaw stiffness / cannot open mouth)
- Rash appears
- Worsening after 48-72 hours on antibiotics
- Adequate fluids - cold drinks, ice cream, and soft foods are soothing
- Rest; avoid school for 3-5 days while febrile
Review in 48-72 Hours
If no improvement → review throat swab result, escalate antibiotic, reassess for quinsy (peritonsillar abscess).
If EBV confirmed on results: Stop penicillin (unless secondary bacterial co-infection), switch to supportive care only, and advise avoiding contact sports for 4-6 weeks due to risk of splenic rupture.
Create a decision flowchart for when to suspect EBV vs bacterial tonsillitis
Generating Image
A clean, professional clinical decision flowchart titled "EBV vs Bacterial Tonsillitis - Decision Flowchart" for medical use. The flowchart starts at the top with "Bilateral Tonsillar Swelling" in a blue header box, then flows downward through decision diamonds and action rectangles. The flow: 1. Start box (blue): "Bilateral Tonsillar Swelling - History & Examination" 2. First diamond: "Age 10-25 years?" - YES arrow goes right, NO arrow goes down 3. From YES: diamond "Posterior cervical lymphadenopathy?" - YES = orange "HIGH SUSPICION FOR EBV" box, NO = continue down 4. From NO (age) and NO (posterior nodes): diamond "Anterior cervical (jugulodigastric) nodes only?" - YES = green "SUSPECT BACTERIAL (GABHS)" box 5. Middle section - two parallel columns comparing features: LEFT column header (orange): "SUSPECT EBV / Glandular Fever" with red flags listed: - Adolescent / young adult - Profound fatigue & malaise - Posterior + generalized lymphadenopathy - Hepatosplenomegaly - Palatal petechiae - Grey-white thick exudates - Rash after amoxicillin - No response to penicillin RIGHT column header (green): "SUSPECT BACTERIAL (GABHS)" with features: - Sudden onset fever >38.5°C - Anterior cervical nodes only - Tonsillar exudates (yellow/white) - No cough - Centor/McIsaac score ≥3 - No hepatosplenomegaly Bottom section - two action boxes: LEFT (orange): "EBV Workup: Monospot / Paul-Bunnell, EBV IgM VCA, FBC (atypical lymphocytes), LFTs, CRP. AVOID amoxicillin/ampicillin. Supportive care. Avoid contact sports if confirmed." RIGHT (green): "Bacterial Workup: Throat swab MC&S, FBC, CRP, ASO titre. Treatment: Penicillin V 500mg BD x 10 days + Paracetamol + Ibuprofen + Dexamethasone" Bottom warning box (red): "⚠ WARNING: Never prescribe amoxicillin until EBV excluded - causes florid maculopapular rash in EBV patients" Use a white background, clear arrows with labels, professional medical color scheme (blue, green, orange, red for warnings), readable fonts, well-spaced layout.
Here is a quick reference summary of the key differentiators used in the flowchart:
EBV vs Bacterial Tonsillitis - At a Glance
| Feature | EBV (Glandular Fever) | Bacterial (GABHS) |
|---|---|---|
| Age | 10-25 years (peak in teens) | Any age, peak 5-15 years |
| Onset | Gradual | Sudden |
| Fatigue | Severe, prolonged | Mild |
| Lymph nodes | Posterior cervical + generalized | Anterior cervical only |
| Organomegaly | Hepatosplenomegaly present | Absent |
| Exudates | Grey-white, thick | Yellow/white pustular |
| Rash | After amoxicillin - maculopapular | Scarlatiniform (Scarlet fever) |
| Cough | May be present | Usually absent |
| FBC | Atypical lymphocytes >10% | Neutrophilia |
| Centor score | Low/unreliable | ≥3 supports GABHS |
The #1 Rule
Never give amoxicillin or ampicillin until EBV is excluded - even one dose causes a widespread rash in EBV patients. Use Penicillin V as the safe default antibiotic in any tonsillitis case where EBV status is unknown.
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