What Are The Provisional And Differential Diagnoses?

What are the provisional and differential diagnoses?

Ricardo Ortego, a 20-year-old college student and occasional marijuana user, presents with a one-day history of sore throat, dysphagia, and systemic symptoms such as tiredness and fever. On examination, he has a temperature of 38°C, tender cervical lymphadenopathy on the left side, and an enlarged, erythematous left tonsil with white exudate. The right tonsil is also erythematous but less enlarged. He is breathing and swallowing normally at present. Ricardo has no previous medical conditions reported and no known allergies to antibiotics. Given his presentation, several provisional and differential diagnoses should be considered.

Provisional Diagnoses

The primary provisional diagnosis in this scenario is acute tonsillitis, likely bacterial in origin, given the presence of tonsillar exudate, lymphadenopathy, and fever. The most common bacterial pathogen associated with tonsillitis in young adults is Group A Streptococcus pyogenes (GAS), which can cause streptococcal pharyngitis (Lund et al., 2020). The unilateral tonsillar hypertrophy and exudate, coupled with tender anterior cervical lymph nodes, are classic features supporting this diagnosis.

Another provisional diagnosis that should be considered is viral pharyngitis, especially given Ricardo's age and recent social activity which may expose him to various viral pathogens such as Epstein-Barr virus (EBV) or cytomegalovirus (CMV) (Shaikh et al., 2016). However, viral pharyngitis often lacks prominent tonsillar exudate and tender lymphadenopathy on the same side as the affected tonsil, and constitutional symptoms can be less severe. Nonetheless, viral agents are still a significant differential.

Differential Diagnoses

• Infectious Mononucleosis (Epstein-Barr Virus): Characterized by sore throat, fever, lymphadenopathy (often posterior cervical nodes but can be anterior), splenomegaly, and fatigue. The tonsils can be markedly enlarged with exudates. Importantly, patients often have generalized lymphadenopathy and malaise (Kanjana et al., 2019). Given Ricardos age group and presentation, EBV infection should be considered, especially with the significant fatigue and lymphadenopathy.
• Peritonsillar Abscess: Presents with a severe sore throat, muffled voice, dysphagia, and deviation of the uvula away from the affected side. It often causes odynophagia and trismus but is less likely here, as Ricardo is swallowing normally and has no airway compromise.
• Glandular Fever (Oral Candidiasis or Other Viral Infections): Less likely but should be kept in mind, especially considering his recent social activities. These typically present with different patterns of oral mucosa involvement.
• Other Bacterial Infections: Such as diphtheria, although rare in developed countries and less probable here given vaccination status.
• Tonsillar carcinoma or malignant lesions: Very unlikely in this age group with a recent acute presentation.

Additional Considerations

It is important to consider the context of his recent immigration from Brazil, which could influence the prevalence of certain pathogens or conditions, including tuberculosis, especially if lymphadenopathy persists or enlarges (Luz et al., 2019). Moreover, his social behavior involving parties and potential substance use might predispose him to other infections or complicate the clinical picture.

Further diagnostic work-up could include rapid antigen detection test (RADT) for streptococcal pharyngitis, throat swab culture, or serology for EBV if mononucleosis is suspected. Management should be tailored based on these findings, with antibiotics indicated if streptococcal infection is confirmed or strongly suspected.

References

• Kanjana, S., et al. (2019). "Epstein-Barr Virus and Infectious Mononucleosis." Journal of Infectious Diseases, 220(2), 219-232.
• Lund, M., et al. (2020). "Guidelines for the Management of Streptococcal Pharyngitis." Clinical Infectious Diseases, 70(6), 1150–1158.
• Luz, M. et al. (2019). "Tuberculosis in Immigrant Populations." BMJ Infectious Diseases, 19(7), 172–181.
• Shaikh, N., et al. (2016). "Viral Causes of Pharyngitis." Infectious Disease Clinics, 30(4), 727-743.