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Why does this tired student have a sore throat?

Dr Mike Wyndham describes the case of a tired student complaining of a recent sore throat

Dr Mike Wyndham describes the case of a tired student complaining of a recent sore throat

The patient

This 19-year-old law student had returned from university at the end of term and was feeling tired from burning the candle at both ends. Two nights previously, she was at a karaoke party and attributed her sore throat to smoking and singing and ‘lubricating her vocal cords'. She thought the glands in her neck were swollen and believed it was time for a course of penicillin as she needed to do some intensive exam revision. She had an excellent health history and was taking a combined oral contraceptive pill.

First instinct

This looked like being my quickest consultation of the day, or even the week. The likeliest cause was going to be viral and I was preparing myself for how I was not going to prescribe antibiotics. But I was somewhat shocked when I saw her throat. There was a marked covering on the left tonsil whereas the right appeared clear. She had a temperature of 37.6°C.

Differential diagnosis

• Group A streptococcal infection

• Infectious mononucloeosis

• Adenovirus infection

Adenovirus infection may manifest in several ways. One serotype may particularly affect the eyes and throat manifesting as sore throat with exudates, fever, coryza and red eyes. The patient only had one of that group of symptoms and so this seemed an unlikely diagnosis.

Group A strep seemed a definite possibility with exudate on the tonsils. What was puzzling was that the ‘exudate' was only on one tonsil.

The symptoms of glandular fever in young people are well known to most: sore throat, fever and swollen glands – particularly in the cervical region. This would certainly fit with the diagnosis.

The hidden clue

Something felt wrong about my impression that this was exudate. It didn't look normal and seemed like a covering, akin to mozzarella on a pizza. I suspected this was a pseudomembrane. Also, the colour looked more off-white, fitting as a comparison with the ‘white' cliffs of Dover.

Getting on the right track

I noticed her upper lids were looking a bit swollen. This is Hoagland sign and is present for a few days in the early stages of glandular fever. The diagnosis of glandular fever was clinched with the pseudomembrane, characteristic Dover white colour and swollen upper lids. With this explained, she was happy to accept a form for a blood test instead of a prescription.

Dr Mike Wyndham is a GP in Edgware, north London

Why does this tired student have a sore throat?

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