We report a case of exudative pharyngitis potentially caused by
A 14-month-old, previously well boy presented to a district hospital in the Western Cape in December 2016 with respiratory distress related to upper airway obstruction. The boy was moderately acutely malnourished and newly diagnosed with HIV on admission.
The child presented with a short history of fever, dysphagia and lethargy. He had a household contact with pulmonary tuberculosis (TB); no TB chemoprophylaxis was given. He had no travel history. Vaccination status was incomplete, with only birth vaccinations administered (Bacille Calmette Guérin [BCG] and oral polio vaccine).
On examination, the child was in shock and had respiratory distress with drooling, forward posturing, grunting and pulsus paradoxus. Oropharyngeal examination revealed an inflamed and oedematous uvula and tonsils with a thick, white, friable membrane adherent to the oropharynx which bled upon touch (
White membrane adherent to the pharynx noted on oropharyngeal examination on presentation in a 14-month-old incompletely vaccinated infant with respiratory distress.
No neck swelling, cervical lymphadenopathy, cranial nerve palsies or muscle weakness was present. Examination of the chest was not suggestive of lower respiratory tract infection.
Potential aetiological considerations included the following: group A streptococcus (
Fluid resuscitation, supplemental oxygen and adrenaline nebulisations were provided.
Ceftriaxone (a third-generation cephalosporin) was given intravenously along with paracetamol. The child was intubated because of worsening respiratory distress and transferred to Tygerberg Hospital’s Paediatric Intensive Care Unit. Diphtheria antitoxin could not be sourced, and was omitted from patient management.
Infection control precautions were followed as for diphtheria whilst awaiting confirmatory results. Standard precautions were combined with droplet precautions, including patient isolation, glove and apron use, and the use of facemasks for both the patient and healthcare providers.
His white cell count was 1.4 × 109/L, haemoglobin 9.0 g/dL and platelet count 54 × 109/L. The serum C-reactive protein (CRP) was 258 mg/L. An HIV-1 antibody test and polymerase chain reaction (PCR) performed on admission were positive. His absolute CD4 (cluster of differentiation 4) count was 356 cells/µL (29%). An HIV viral load was not performed.
Epstein–Barr virus serology supported previous exposure (EBV nuclear antigen IgG positive, EBV viral capsid antigen IgM negative). Herpes Simplex Virus 1/2 and adenovirus PCR were negative.
Blood cultures revealed no growth.
A tracheal aspirate on admission showed occasional non-branching small Gram-positive bacilli in Chinese letter formation and no neutrophils on Gram stain, and revealed no growth after 48 h in a 5% CO2-enriched incubator. A nasal swab taken on admission showed a pure growth of
Two throat swabs taken in the first 24 h of admission (one prior to antibiotics) showed no pathogens after 72 h of incubation. The throat swabs and a nasal swab were also cultured and tested molecularly at the National Institute for Communicable Diseases and were culture-negative and PCR-negative for
The patient improved steadily on a 14-day course of ceftriaxone. Antiretroviral therapy and catch-up vaccinations
Nasal and throat swabs were collected from 36 asymptomatic household and healthcare contacts.
Throat and nasal swabs were inoculated onto tellurite-containing and routine media and incubated at 35 °C in ambient and 5% CO2-containing incubators, respectively; colony growth was better in the CO2-enriched atmosphere. Grey-black colonies suspicious of
Neither beta-haemolytic colonies nor yeasts were cultured from any of the samples.
Biochemical identification with the VITEK(R) 2 ANC system (bioMérieux, Marcy l’Etoile, France) confirmed by the BD BBL Crystal™ Gram Positive ID Kit (Becton Dickinson and Company, Franklin Lakes, USA), convincingly identified
Limited susceptibility testing was performed using the gradient-diffusion based E-test method (bioMérieux, Marcy l’Etoile, France). Results were interpreted using
Antimicrobial susceptibility testing results of the
Antimicrobial agent tested | Minimum inhibitory concentration (μg/mL) |
Interpretation category for |
---|---|---|
Penicillin | 0.012 | Susceptible |
Cefotaxime/Ceftriaxone | 0.047 | Susceptible |
Ciprofloxacin | 0.094 | Susceptible |
Vancomycin | 0.19 | Susceptible |
Azithromycin | 0.125 | - |
CLSI, Clinical and Laboratory Standards Institute M45 document, 3rd edition 2015.
, Minimum inhibitory concentration obtained by gradient diffusion testing (Etest, bioMérieux, Marcy l’Etoile, France).
Informed consent was obtained from the child’s mother and ethical approval was granted by Stellenbosch University’s Human Health Research Ethics Committee (Reference number C20/01/002).
These infections have largely been noted in patients who are immunosuppressed, such as HIV-positive patients or transplant recipients; patients with underlying lung disease, such as chronic obstructive airways disease; and patients with underlying medical conditions, such as congestive cardiac failure, ischaemic heart disease and malignancy.
Pulmonary infection has also been linked to invasive respiratory procedures such as endotracheal intubation, presumably because of direct introduction of this commensal into the lung.
Co-infection with recognised respiratory tract pathogens has been reported
Other infectious processes associated with
A summary of important clinical features in reported cases of
Variable | Case 1 – 1996 |
Case 2 – 1997 |
Case 3 – 2014 |
---|---|---|---|
Age | 32-year old | 4-year old | 6-year old |
Gender | Male | Female | Female |
Presenting symptom | Sore throat, dysphagia, fever | Fever, generalised lymphadenopathy | Fever, sore throat, neck swelling, nasal obstruction, toxic |
Oropharynx | Greyish-white exudate from tonsils to posterior pharyngeal wall, enlarged tonsils, tender cervical lymphadenopathy, erythema and oedema | Greyish-white membrane attached to posterior pharyngeal wall, erythema | White, leathery membrane over tonsils, congestion, cervical lymphadenopathy |
Underlying history | Not reported | Not reported | Not reported |
Treatment | Penicillin IM, diphtheria antitoxin | Cefprozil and erythromycin | Penicillin IV, diphtheria antitoxin |
Outcome | Cured | Cured | Cured |
Immunisation history | ‘All’ received in childhood | Not immunised | Fully immunised |
Note: Please see the full reference list of the article, Reddy K, Gericke S, Rabie H, Pienaar C, Maloba M. Exudative pharyngitis and
IM, intramuscular; IV, intravenous.
, Santos et al.
, Izurieta et al.
, Indumathi et al.
Despite the fact that
The identification of
Common, presently available biochemical/proteomic methods to identify
VITEK® 2 ANC (bioMérieux, Marcy l’Etoile, France):
BD BBL Crystal™ Gram Positive ID (Becton Dickinson and Company, Franklin Lakes, USA): Correctly identified 7 of 12 control
API® Coryne version 4.0 (bioMérieux, Marcy l’Etoile, France): Correctly identified one control strain as
Vitek MS (bioMérieux, Marcy l’Etoile, France): 77% of 114
Macrolide and lincosamide resistance occurs consistently,
The limitations of this case study include the isolation of this organism from only a single admission nasal swab with a suggestive but unproven causative link and the absence of comprehensive antibiotic susceptibility testing. We did not assess strain relatedness between isolates, although the absence of this organism from any other contacts screened increases the likelihood of these being genetically related. The production of a novel toxin producing similar effects to diphtheria toxin was not explored and could be researched in future studies.
This case adds evidence to the likely role of
The authors wish to thank the staff at the National Health Laboratory Services (NHLS) Tygerberg, the National Institute for Communicable Diseases’ Centre for Respiratory Diseases and Meningitis, and Mr Valentino Horne (NHLS Greenpoint) for their assistance with the laboratory testing of this isolate. We would like to acknowledge Professors Lucille Blumberg and Anne von Gottberg, Sister Marina Aucamp and the Western Cape Provincial Communicable Disease Co-ordination team for their advice and support. The patients and the dedicated staff at Tygerberg Hospital’s Department of Paediatrics made this research possible.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this case report.
K.R. conceptualised the study and formulated the manuscript. S.G. and H.R. completed the clinical presentation component. C.P. and M.M. critically reviewed the manuscript.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy of any affiliated agency of the authors.