Case of Recurrent Pharyngotonsillitis with Persistent Exudates Following Multiple Antibiotic Courses

Case at a Glance

A 26-year-old female presents with a two-month history of recurrent pharyngotonsillitis, characterized by persistent tonsillar exudates despite sequential treatment with three different classes of antibiotics. The case highlights the challenges of managing recurrent throat infections without initial microbiological confirmation and in the context of a reported, but unverified, penicillin allergy.

Patient's Story

The patient, a 26-year-old female, initially sought medical attention at an after-hours clinic for a severe sore throat. She was visually diagnosed with streptococcal pharyngitis. Due to a reported history of hives in response to penicillin as an infant, she was treated with a non-penicillin antibiotic. Despite completing the full course, her symptoms only partially resolved. A subsequent course of a different antibiotic seemed to clear the infection, but her symptoms relapsed within days of completing the medication. Concerned about an impending month-long international trip, she sought care again but was advised her immune system should be able to clear the residual infection. However, given her travel plans, she was prescribed a third course of antibiotics. While this also seemed effective initially, the symptoms once again returned after she finished the medication. Now, two months since the initial onset, she continues to experience a sore throat and visible exudates, raising concerns about the chronicity of the infection and potential complications.

Initial Assessment

The patient first presented with a chief complaint of a severe sore throat. Physical examination by the initial physician revealed a markedly swollen right tonsil with thick white and grey patches of exudate. A diagnosis of streptococcal pharyngitis was made based on clinical appearance alone, without a rapid antigen detection test (RADT) or throat culture. A patient-reported history of a possible penicillin allergy (hives in infancy, details uncertain) was noted, guiding the initial choice of antibiotic.

The Diagnostic Journey

The patient's treatment course was sequential and marked by relapses:

First-line Treatment: Cephalexin 500mg twice daily for 10 days. At the end of the course, tonsillar swelling had decreased, but the exudates persisted as smaller white spots.
Second-line Treatment: Following a visit to her primary GP, who noted the persistence of pus as unusual, she was prescribed roxithromycin 150mg twice daily for 10 days. Symptoms appeared to resolve completely during treatment. However, two days after completing the course, the tonsillar exudates reappeared, followed by a sore throat, though less severe than the initial presentation.
Third-line Treatment: Prior to international travel, she was prescribed clarithromycin 250mg. She completed a 13-day course while overseas. Again, symptoms resolved during treatment but began to return approximately 11 days after cessation of the antibiotic.

Throughout this period, no microbiological testing was performed to confirm the pathogen or its antibiotic sensitivities. Photographic evidence provided by the patient confirmed erythematous tonsils with visible white exudates, consistent with her self-report.

Final Diagnosis

Unresolved Recurrent Pharyngotonsillitis. The etiology remains unconfirmed but is presumed to be bacterial, likely due to treatment failure, antibiotic resistance, or bacterial biofilm formation. Atypical or viral causes cannot be excluded without further testing. A definitive diagnosis is pending microbiological investigation.

Treatment Plan

The patient has been managed with three sequential courses of antibiotics without lasting resolution:

Course 1: Cephalexin (a first-generation cephalosporin)
Course 2: Roxithromycin (a macrolide)
Course 3: Clarithromycin (a macrolide)

The proposed plan upon her return home is to seek consultation with her primary care physician for a comprehensive evaluation, including:

A throat swab for culture and sensitivity testing to identify the causative organism and guide targeted antibiotic therapy.
Consideration for infectious mononucleosis testing (e.g., Monospot test) to rule out a viral cause like Epstein-Barr virus (EBV).
Referral for allergy testing to formally assess her penicillin allergy status, which could significantly broaden future treatment options.

Outcome and Follow-up

The patient's condition is ongoing, with persistent symptoms despite multiple antibiotic courses. The short-term outcome is poor, characterized by a cycle of temporary improvement followed by relapse. The critical follow-up step is the planned visit to her GP for definitive diagnostic testing. This case underscores the importance of obtaining microbiological confirmation in cases of recurrent or refractory pharyngotonsillitis to ensure appropriate and effective antimicrobial therapy.