Wednesday, April 15, 2009

A simple case of misdiagnosis .....

Being a doctor I always feel that there would be less chances of misdiagnosis in my case. I know the doctors, their reputation, and many are friends too. So this weekend when I developed pus in my tonsils, I first took a course of "mild" antibiotic Azithromycin. Since that did not work, I talked to an ENT specialist friend, and he recommended a course of Clindamycin, after having a look and saying that I had a lot of pus in both the tonsils. For those of you who have taken this medicine, you know the gastritis, loose motions etc. that are a part and parcel of taking it. However, I did take this as directed. However after 3 days of continuously missing my clinic practice due to fever, body aches and general malaise, I got a second opinion from another ENT specialist today. He had a look, and immediately exclaimed that this is a VIRAL tonsillopharyngitis, and it would recover faster with just a short course of oral steroids. No need for any antibiotics! This was amazing, and I am starting to feel better already :-)

I asked him and searched online for tips regarding how to differentiate the two conditions, since we do get a lot of purulent tonsillitis in my pediatric practice too.

While of course there are no hard and fast rules, generally viral tonsillitis would have small ulcers else where too, other than the tonsils, and the tonsils would not be angry red or enlarged. There would be more pain during speaking, and lots of malaise, but not very high fever nor toxic look in cases of children with viral tonsillitis. Small ulcerations on the other areas of the throat would be pathognomonic for viral tonsillitis, though in cases of doubt, a simple blood count would help differentiate the two conditions. Scratchy feeling in the throat, and other symptoms like cold, cough etc. are likely to occur. Generally the neck lymphnodes are not significantly enlarged nor painful in viral pharyngitis. Viral purulent tonsillitis is less common in children, and starts appearing in teenagers and older adults.

Strep tonsillitis is the most important differential between commonly occurring between 3-15 years age. Bacterial pharyngitis generally has higher fever, no flu like symptoms, and painful enlarged lymphnodes. There may be a petechial rash over the palate / uvula. Strep throat swabs are not easily available / routinely used in India at present, though this is likely to change, so immediate diagnosis is not possible, and antibiotics are generally given to everyone with purulent tonsillitis.

Well a lesson learnt about viral / bacterial tonsillopharyngitis, and that even simple conditions can be misdiagnosed leading to unnecessary suffering and missed work. While we do read about this, it really hits home when it happens to you I guess!

The other thing that I realized was that even for a "trivial" illness like tonsillitis, finding a better doctor can make such a difference, imagine how much difference it would make for serious and life threatening diseases?!


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