HEMORRHAGIC TONSILLITIS AS A RARE

PRESENTATION OF TONSILLITIS: A CASE REPORT

Hiyam Shamo'on, MD*, Rania Hadaddin, MD*

ABSTRACT
Hemorrhagic tonsillitis is a rare complication of acute or chronic tonsillitis and could be fatal in some cases.
Few cases were reported in the literature. Here we present a seven years old female child who was presented
with bilateral tonsillar hemorrhage and a history of chronic recurrent tonsillitis. Her investigations and
management are discussed.

Key words: Hemorrhagic, Streptococcus, Tonsillitis, Bleeding

JRMS February 2010, 17(Supp 1): 33-34

Introduction

Case Report

The tonsils are lymph tissues located on either side

of the back of the throat. Their functions are to
destroy microorganisms entering the nose and
throat. Most episodes of acute pharyngotonsillitis
are viral. Group A beta-hemolytic Streptococcus is
the most common cause of bacterial infection in the
tonsils. Others causes are beta-hemolytic
Streptococcus species (Lancefield Groups, Group C
or B),(1,2) Staphylococcus aureus, gram-negative
organisms and Mycoplasma pneumonia are other
causes.(1)
Hemorrhagic tonsillitis, which is a complication of
acute or chronic tonsillitis, is almost always found
in association with peritonsillar abscess and is rarely
reported in the new antibiotic era. It is a serious
condition and could be fatal in some cases if
hemorrhage was not controlled from tonsillar blood
vessels.(3)
Here we report the case of a seven years old female
child with severe toxicity, follicular tonsillitis, and
bleeding tonsils that presented to our emergency
pediatric clinic, and was diagnosed as a case of
hemorrhagic tonsillitis.

A seven years old female child presented to our

outpatients pediatric clinic with high fever,
toxicity, malaise, inability to swallow, and sore
throat. Physical examination showed a blood
pressure of 90/40mmHg, pulse 100/minute and
axillary temperature of 39 degrees Celcius. Throat
examination showed follicular tonsillitis with
bleeding tonsils (Fig.1). An otorhinolaryngologist
(ENT) doctor was consulted and otopharyngeal
examination showed hugely enlarged, swollen,
congested and bluish tonsils bilaterally with whitish
debris on both of them. There were diffuse
superficial oozing points on both tonsils and
bilateral tender and enlarged cervical lymph nodes.
A pack soaked with 2% hydrogen peroxide was
applied locally for both sides and silver nitrate
cautery was done which controlled the bleeding
points. Her throat swab showed alpha-hemolytic
Streptococcus, no serological typing for the isolated
Streptococcus was done. Complete blood count
showed Leucocytosis with neutrophilia. Her
prothrombin time (PT) and partial thromboplastin
time (PTT) were normal. Liver and kidney function
tests were normal. IgM antibodies were negative for

*From the Department of Pediatrics, Queen Alia Military Hospital, Amman-Jordan

Correspondences should be addressed to Dr. H Shamo'on, P. O. Box 960933 Amman 11196 Jordan. E-mail: hshamoon@ yahoo.com
Manuscript received December 1, 2004. Accepted April 27, 2005

JOURNAL OF THE ROYAL MEDICAL SERVICES

Vol. 17 Supp No. 1 February 2010

33

No other reported case was found associated with

this organism.
In 1996, Tamimi et al. reported three cases of
spontaneous hemorrhages from the tonsils, which
were treated conservatively, and tonsillectomies
were not performed at the time of presentation(3) as
in our case. Uncontrolled hemorrhages from
tonsillar blood vessels are an absolute indication for
tonsillectomy but their occurrence is rare.(5-8)
Our child was treated conservatively at the time
of presentation by chemical cautery and she
underwent tonsillectomy two months later for her
recurrent tonsillitis (more than seven episodes of
follicular tonsillitis in the previous year).
Fig. 1. Hugely enlarged, congested, and bleeding tonsils
with few follicles

Ebstein, vital capsid antigen (VCA) and

Cytomegalovirus. No other viral serology or culture
was done. Cold agglutinin antibodies were negative.
C-reactive protein (CRP) was 48 mg/dl (normal
being below 6 mg/dl) and the blood culture was
negative. Immediately the child was started on
crystalline penicillin 200 mg/kg/day and amikacin
20 mg/kg/day, which were given parentally for five
days. The child improved and was discharged from
hospital on oral penicillin V for another five days.
Elective tonsillectomy was done two months later.

Conclusion
Hemorrhagic tonsillitis is a serious complication
of acute or chronic tonsillitis and is still seen, even
in our new antibiotic era. Tonsillectomy may be
needed on an emergency or elective basis according
to individual evaluation.

Acknowledgment
We are thankful to Dr Sami Jmeian for his help in
diagnosing and treating this child.

References
1. Wetmore RF. Tonsil and Adenoids. In: Behrman RE,

Discussion
Hemorrhagic tonsillitis is a rarely reported
complication of tonsillitis especially chronic
tonsillitis.(3) Other causes may be involved as
malignancy or bleeding diathesis.(4) The acute
inflammatory response increases blood flow to the
tonsils with secondary edema, vascular congestion,
dilated surface vessels, and necrosis of tonsillar
surface cells. These dilated vessels may bleed due to
vessel wall erosion secondary to bacterial infection
or infectious mononucleosis.(3- 5)
Levy(4) reported eleven cases in a pediatric
population from 1983-1986. Seven patients had a
previous history of tonsillitis. Eight patients had
dilated surface vessels that were the source of the
hemorrhage and two had diffuse parenchymal
bleeding. Fifty five percent had cultures positive for
group A beta-hemolytic Streptococcus.(3) Our
patient's throat swab showed alpha-hemolytic
Streptococcus.

34

2.
3.
4.
5.
6.
7.
8.

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Tamimi SF, Twalbeh M, Al-Amr I, Gudah K.
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Levy S, Brodsky L, Stanievich J. Hemorrhagic
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Deutsch ES. Tonsillectomy and adenoidectomy,
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