Febrile exudative tonsillitis: viral or streptococcal?

A prospective 1-year study of acute febrile exudative tonsillitis in 110 children was carried out. Viral infection was associated with 42% of the cases, beta-hemolytic streptococci with 31% (12% group A), Mycoplasma pneumoniae with 5%, and unknown cause with 35%. More than one agent was implicated in 14% of the cases. Adenovirus was the viral agent most frequently (19%) recorded. Other viruses involved were Epstein-Barr virus, parainfluenza, influenza A, herpes simplex, and respiratory syncytial viruses. The responsible agent was found by rapid viral antigen detection in 20% of all cases and by rapid test for group A streptococcal antigen detection in 10%. Age was the most important factor in predicting the causative agent. Viral tonsillitis was most common in children younger than 3 years of age and group A beta-hemolytic streptococci tonsillitis in children 6 years of age or more. Clinical analysis of the illness, WBC count, and ESR did not reveal differences that could help in differentiating bacterial from viral tonsillitis. All patients were treated with a regimen of oral penicillin. Fever associated with group A beta-hemolytic streptococci tonsillitis responded to penicillin therapy significantly more rapidly than fever associated with viral infections. These observations demonstrate the prominent role of viruses in the etiology of febrile exudative tonsillitis, especially in young children, and reinforce the benefit of rapid tests before antibiotic therapy is started.