Bilateral peritonsillar abscesses complicating acute tonsillitis.

1276 CMAJ, August 9, 2011, 183(11) © 2011 Canadian Medical Association or its licensors A24-year-old woman presented to the emergency department with a three-day history of worsening sore throat, pain with swallowing and fever. She had been seen by her primary care physician one day before presentation because of sore throat and fever, and had been given oral amoxicillin. She was previously well with no history of recurrent tonsillitis, previous peritonsillar abscess or drug allergies. On physical examination, her temperature was 39.8°C, pulse rate was 90 beats/min, res piratory rate was 24 breaths/min and blood pressure was 110/70 mm Hg. She spoke with a muffled voice without substantial stridor or respiratory distress. Examination of the oral cavity and oropharynx showed moderate trismus, pooling of saliva, symmetrically enlarged and in flamed tonsils, and a bilaterally congested and bulging soft palate with a midline uvula (Figure 1). There was also bilateral, tender submandibular lymphadenopathy. The remainder of the physical examination was unremarkable. A complete blood count showed a leukocyte count of 17.6 (normal 4.5–11.0) × 10/L with an elevated absolute neutrophil count of 15.7 (normal 1.8–8.1) × 10/L. The absolute lymphocyte count and monocyte count were within normal limits. The level of C-reactive protein was 3926.8 (normal < 47.6) nmol/L. A monospot test was not done. On her arrival at the emergency department, the patient was given intravenous (IV) fluids and IV amoxicillin–clavulanic acid for a provisional diagnosis of peritonsillar abscess. Contrast-enhanced computed tomography (CT) of the neck showed bilateral hypodense masses with thick rim enhancement in the superior poles of the peritonsillar regions measuring 2.6 × 1.8 cm and 0.8 × 0.8 cm, respectively (Figure 2A), and extending down to the peritonsillar regions with a multilocular appearance (Figure 2B), consistent with bilateral peritonsillar ab scesses. The patient underwent bilateral needle aspiration by the otolaryngologist; a total of 10 mL of purulent material was obtained from the left side and 3 mL from the right side. Cultures from the aspiration ultimately grew Acinetobacter baumannii, which was resistant to ampicillin and susceptible to ampicillin–sulbactam. She was discharged home on another course of oral amoxicillin–clavulanic acid for a total of 14 days of antibiotic treatment. The patient’s abscesses resolved and there were no signs of recurrence at six months.