Clinical practice guideline: tonsillitis II. Surgical management.

In 2013, a total of 84,332 patients had undergone extracapsular tonsillectomies (TE) and 11,493 a tonsillotomy (TT) procedure in Germany. While the latter is increasingly performed, the number of the former is continually decreasing. However, a constant number of approximately 12,000 surgical procedures in terms of abscess-tonsillectomies or incision and drainage are annually performed in Germany to treat patients with a peritonsillar abscess. The purpose of this part of the clinical guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through the surgical treatment options to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical treatment options encompass intracapsular as well as extracapsular tonsil surgery and are related to three distinct entities: recurrent episodes of (1) acute tonsillitis, (2) peritonsillar abscess and (3) infectious mononucleosis. Conservative management of these entities is subject of part I of this guideline. (1) The quality of evidence for TE to resolve recurrent episodes of tonsillitis is moderate for children and low for adults. Conclusions concerning the efficacy of TE on the number of sore throat episodes per year are limited to 12 postoperative months in children and 5-6 months in adults. The impact of TE on the number of sore throat episodes per year in children is modest. Due to the heterogeneity of data, no firm conclusions on the effectiveness of TE in adults can be drawn. There is still an urgent need for further research to reliably estimate the value of TE compared to non-surgical therapy of tonsillitis/tonsillo-pharyngitis. The impact of TE on quality of life is considered as being positive, but further research is mandatory to establish appropriate inventories and standardized evaluation procedures, especially in children. In contrast to TE, TT or comparable procedures are characterized by a substantially lower postoperative morbidity in terms of pain and bleeding. Although tonsillar tissue remains along the capsule, the outcome appears not to differ from TE, at least in the pediatric population and young adults. Age and a history of tonsillitis are not a contraindication, abscess formation in the tonsillar remnants is an extremely rare finding. The volume of the tonsils should be graded according to Brodsky and a grade >1 is considered to be eligible for TT. The number of episodes during 12 months prior to presentation is crucial to indicate either TE or TT. While surgery is not indicated in patients with less than three episodes, a wait-and-see policy for 6 months is justified to include the potential of a spontaneous healing before surgery is considered. Six or more episodes appear to justify tonsil surgery. (2) Needle aspiration, incision and drainage, and abscess tonsillectomy are effective methods to treat patients with peritonsillar abscess. Compliance and ability of the patient to cooperate must be taken into account when choosing the surgical method. Simultaneous antibiotic therapy is recommended but still subject of scientific research. Abscess tonsillectomy should be preferred, if complications have occurred or if alternative therapeutic procedures had failed. Simultaneous TE of the contralateral side should only be performed when criteria for elective TE are matched or in cases of bilateral peritonsillar abscess. Needle aspiration or incision and drainage should be preferred if co-morbidities exist or an increased surgical risk or coagulation disorders are present. Recurrences of peritonsillar abscesses after needle aspiration or incision and drainage are rare. Interval TE should not be performed, the approach is not supported by contemporary clinical studies. (3) In patients with infectious mononucleosis TE should not be performed as a routine procedure for symptom control. TE is indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia. If signs of a concomitant bacterial infection are not present, antibiotics should not be applied. Steroids may be administered for symptom relief.

Acute juvenile pityriasis rubra pilaris: a case report after mononucleosis infection.

A 24-year-old male boy presented dermatosis which first appeared acutely after an infection at age 17. Clinical and histopathologic examinations were consistent with a diagnosis of juvenile pityriasis rubra pilaris type III. Treatment with UVB narrow-band led to complete resolution of the dermatitis within 1 year. Pityriasis rubra pilaris is a papulosquamous disorder of unknown etiology, which can be treated with retinoids, methotrexate, cyclosporine, and narrow-band phototherapy.

Effect of compound glycyrrhizin injection on liver function and cellular immunity of children with infectious mononucleosis complicated liver impairment.

OBJECTIVE: To investigate the effects of Compound Glycyrrhizin Injection (CGI) on liver function and cellular immunity of children with infectious mononucleosis complicated liver impairment (IM-LI) and to explore its clinical therapeutic effect. METHODS: Forty-two patients with IM-LI were randomly assigned, according to the randomizing number table, to two groups, 20 in the control group and 22 in the treated group. All the patients were treated with conventional treatment, but to those in the treated group, CGI was given additionally once a day, at the dosage of 10 ml for children aged below 2 years, 20 ml for 2-4 years old, 30 ml for 5-7 years old and 40 ml for 8- 12 years old, in 100-200 ml of 5% glucose solution by intravenous dripping. The treatment lasted for 2 weeks. T lymphocyte subsets and serum levels of alanine transaminase (ALT), aspartate aminotransferase (AST) and total bilirubin (TBil) were detected before and after treatment. Besides, a normal control group consisting of 20 healthy children was also set up. RESULTS: Baseline of the percentage of CD3 + , CD8 + lymphocyte and serum levels of ALT, AST, TBiL in the children with IM-LI were markedly higher, while the percentage of CD4 + lymphocyte and the CD4 + /CD8 + ratio was markedly lower in IM-LI children as compared with the corresponding indices in the healthy children ( P<0.01). These indices were improved after treatment in both groups of patients, but the improvement in the treated group was better than that in the control group (P<0.01). CONCLUSION: Cellular immunity dysfunction often occurs in patients with IM-LI, and CGI treatment can not only obviously promote the recovery of liver function, but also regulate the immune function in organism.

Síndrome febril prolongado con linfadenopatías: actualización y revisión del tema / Prolonged febrile syndrome with lymphadenopathy: update and review of this process

Presentamos una serie de 5 pacientes con síndrome febril prolongado con linfadenopatías (S.F.P.LA.), 2 de sexo masculino y 3 de sexo femenino, entre 16 y 55 años de edad. La etiología fue: lupus eritematoso sistémico (n=1), sarcoidosis (n=1), síndrome de Felty (n=1), linfadenopatía angioinmunoblástica (n=1) y mononucleosis infecciosa (n=1). Todos los casos fueron diagnosticados entre 1997 y 2002. Realizamos además una revisión y actualización del tema. (AU)

Common variable immunodeficiency following Epstein-Barr virus infection.

The authors present a case of a patient who developed recurrent bacterial upper respiratory and pulmonary infections and marked hypogammaglobulinemia with a gradual decrease of serum IgG, IgA and IgM some months after acute Epstein-Barr virus infection. Test for identification of lymphocyte subpopulation showed increased CD8+ T-cells with a surface phenotype (CD8+, CD57+, HLA-DR+) characteristic of virus-induced, activated cytotoxic cells. Viral investigations showed a positive anti-EBNA titer, an IgG titer anti-VCA of 1:40, a negative IgG titer anti-EA and human immunodeficiency virus negativity. The authors conclude that these clinical features are indicative of possible common variable immunodeficiency following Epstein-Barr virus infection.

An uncommon presentation for a common problem.

One of the axioms of general practice is that 'common things present commonly', both in the community incidence of disease and in the symptoms with which illnesses usually present. This was somewhat enigmatically put by a renowned neurologist at the Mayo Clinic: "When you hear hoof-beats, why think of zebras?". A most difficult, yet important feat for the GP is to keep on the alert for the uncommon symptom of a common cause, and the common symptom with an uncommon cause.

Cardiomyopathy associated with nonendemic selenium deficiency in a Caucasian adolescent.

We describe a girl aged 17 y who died after a cardiac arrest secondary to septic shock. At autopsy, the enlarged, soft, and flabby heart showed microscopic evidence of acute myocardial infarction, myocardial edema, myocardiocyte loss, replacement fibrosis in the interventricular septum, and right and left ventricular hypertrophic nucleomegaly. The pathological diagnosis was that of cardiomyopathy due to prolonged selenium deficiency. The patient had been on total parenteral nutrition for 17 mo, following extensive bowel resection for intractable pain, nausea, and vomiting caused by chronic idiopathic intestinal pseudoobstruction. Seven months before death, when severe biochemical selenium deficiency was diagnosed, supplemental selenium was added to the infusion, and plasma selenium concentrations increased. In long-standing selenium deficiency, sepsis may contribute the final insult to a damaged myocardium, triggering symptomatic cardiac failure and sudden death.