Letter to the Editor     October 2020  

Tonsillitis as a Rare Manifestation of COVID-19

By Kainat Fatima1, Syeda Ghadeer Zehra Naqvi2

Affiliations

  1. Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan
  2. Jinnah Sindh Medical University (JSMU), Karachi, Pakistan

Sir,

Coronaviruses, including the novel severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV2), cause illnesses ranging from common flu to severe respiratory illnesses, multiorgan failure and death. The lower respiratory illnesses commonly present with cough, dyspnea, chest tightness and fever.Disease manifestations may include upper respiratory symptoms such as sore throat, pharyngeal edema, and nasal congestion. Literature review revealed that no many studies are available on ear, nose and throat (ENT) manifestations in coronavirus disease 2019 (COVID-19) patients.2

Acute tonsillitis is commonly caused by Epstein bar virus, adenoviruses, influenza and para-influenza viruses, rhinoviruses and coronaviruses.3 Although acute tonsillitis is quite uncommon manifestation in COVID-19 patients, we report a case of acute tonsillitis and sore throat in a COVID-19 infected patient.

Figure 1: Inflamed tonsils showing redness and pus.

A 24-year female, a confirmed case of COVID-19, presented with fever, sore throat and difficulty in swallowing for the past 12 hours. The above symptoms were associated with generalised weakness, abdominal pain, loss of sense of taste and myalgia. The patient complained that despite taking erythromycin for sore throat two times per day for two days, there was no improvement.  Past surgical and medical history was insignificant and family history was positive for three active cases of COVID-19. On general physical examination, the patient was mildly dehydrated with muffling speech; and oral examination showed inflammation of right-sided palatine tonsil with redness and pus over the palatoglossal fold (Figure 1). The patient was prescribed pain medication, paracetamol and synflex BD, gargles with salt water, maintenance of oral hygiene with enziclor; and was advised to take warm liquids and antibiotic course.

The mechanism of ENT involvement in COVID-19 disease has not been duly studied. It is usually considered to involve lower respiratory tract. However, COVID-19 viruses detected in oropharyngeal and nasal swabs.High viral load at these sites suggests ENT and upper respiratory tract involvement. Upper respiratory tract involvement reported presence of sore throat in 5% to 17.4%, pharyngodynia in 13.9% and nasal congestion in 4.8% of COVID-19 patients.2,4 Some ENT-related symptoms such as sinusitis, mastoiditis and peri-pharyngeal collection are suspected to be associated with disease.5 Knowledge of ENT involvement by coronaviruses is important for both scientific and public health concerns. To the best of our knowledge, this is the first reported case mentioning simultaneous occurrence of tonsillitis and COVID-19. This case highlights the importance of keeping high index suspicion of COVID-19 infection in patients presenting with tonsillitis. Proper history related to symptoms of COVID-19 should be taken by patients to rule out COVID-19. Pertaining to this case, ENT physicians are at risk and should be advised to take proper protective and sanitation measures to avoid spread of this contagious disease.

CONFLICT OF INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
KF: Concept, design, literature review, drafting, final approval of version to be published.
SGZN: Data acquisition, design, drafting, content editing.

REFERENCES

  1. Sen DJ, Mandal SK, Biswas A, Dastider D, Mahanti B. Corona is culprit of ridiculous offensive  nonsense air. World J Pharm Res 2020; 9(4):503-18.
  2. El-Anwar MW, Elzayat S, Fouad YA. ENT manifestation in COVID-19 patients. Auris Nasus Larynx 2020; 47(4):559-64. doi: 10.1016/j.anl.2020.06.003.
  3. Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R. Clinical practice guideline: Tonsillitis I. Diagnostics and nonsurgical management. Eur Arch of Otorhinolaryngol 2016; 273(4):973-87. doi: 10.1007/s00405-015-3872-6.
  4. Lovato A, de Filippis C, Marioni G. Upper airway symptoms in coronavirus disease 2019 (COVID-19). Am J Otolaryngol 2020; 41(3):102474. doi: 10.1016/j.amjoto. 2020.102474.
  5. Leboulanger N, Sagardoy T, Akkari M, Ayari-Khalfallah S, Celerier C, Fayoux P, et al. COVID-19 and ENT pediatric otolaryngology during the COVID-19 pandemic. Guidelines of the French association of pediatric otorhinolaryngology (AFOP) and French society of otorhinolaryngology (SFORL). Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137(3):177-81. doi: 10.1016/ j.anorl.2020.04.010.