Contributed by Allene Gagliano, MDFINAL DIAGNOSIS:
Marked reactive lymphoid hyperplasia with focal herpetic type inclusions.
An addendum stated that in light of the EBER result, the possibility that there could be a co-infection with EBV cannot be ruled out; however, this might simply represent evidence of prior infection.
DISCUSSION:
In a case report of a similar presentation, a 22 year old female presented with a history of fever, sore throat and N/V. She was s/p a 10 day course of erythromycin. Cultures and serologic studies for beta-hemolytic Grp. A Strep. and HIV were negative, as was the monospot test. The patient had a negative history of STDs or mucocutaneous herpetic lesions in oral or genital areas.
On physical exam, the patient had exudative tonsillitis and bilateral tender cervical lymphadenopathy. There was tonsillar asymmetry with right sided prominence suggestive of peritonsillar abscess. Initially, a single, small aphthous appearing ulcer was seen on the lower lip. Subsequently, several similar ulcers formed within the oral cavity. Her WBC count was 10.3 x 109/L with 87% segs, 9% lymphs and 4% macrophages. After 3 days of continued fever despite IV antibiotics, tonsillectomy was performed. After histologic diagnosis/culture results were reported, the patient was given acyclovir for 16 days with improvement.
Histology revealed severe lymphoid hyperplasia and focal geographic zones of necrosis distinguished by karyorrhectic debris and cells with intranuclear viral inclusions. Occasional cells with smudged "ground glass" and intranuclear inclusions; multinucleated giant cells with intranuclear inclusions. Follicular hyperplasia and paracortical expansion with numerous reactive immunoblasts were also seen. The specimen showed strong reactivity with antibody to HSV antigens.
HSV infections can occasionally involve the tonsils. However, because tonsillectomy is seldom necessary, histologic findings are not well described. The DDx of herpes tonsillitis includes other viral infections such as EBV and CMV. EBV infection will frequently have associated systemic complaints, peripheral lymphocytosis and atypical lymphocytes and histologically will show negative HSV immunostains and no viral inclusions will be seen on H & E. Additionally, serologic studies are available to confirm primary EBV infection. CMV infection, on the other hand, shows characteristic large purple intranuclear inclusions with a surrounding clear halo and smaller cytoplasmic inclusions. Additionally, specimens will be HSV immunostain negative, and CMV nuclear and cytoplasmic stains should be positive.
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Contributed by Allene Gagliano, MD
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