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Am Fam Physician. 2019;99(2):77

To the Editor: An 18-year-old female presented to clinic with three days of painful, swollen tonsils in the setting of recurrent tonsillitis. She reported ear pain with swallowing, but no fevers, dysphagia, or cough. She visited urgent care two months prior for the same complaint and was treated for streptococcal pharyngitis despite a negative rapid strep test. She reported four to five episodes of tonsillitis each year. A comprehensive sexual history revealed the patient engaged in penile-oral sex.

Physical examination was notable for edematous tonsils with white exudate and tender submental lymphadenopathy. She was afebrile, and there was no erythema of the pharynx. Rapid strep testing was negative, but an additional tonsillar swab returned positive for gonorrhea. The patient's urine was also positive for gonorrhea, but screening for HIV, chlamydia, and trichomoniasis was negative. The patient was informed of the results and returned to clinic for intramuscular ceftriaxone (Rocephin) and was prescribed azithromycin (Zithromax).

Gonorrhea is the second most common reportable disease in the United States behind only chlamydia.13 The number of reported cases of gonorrhea has risen steadily since a historic low in 2009, an increase of 48.6% from 2009 to 2016.3 Adolescents and young adults 15 to 29 years of age account for most new cases.2,3 Although gonococcal tonsillitis is a well-described infection, diagnosis requires taking a sexual history.4 Although sometimes asymptomatic, gonococcal tonsillitis presents with sore throat in 64% of cases. Fever and cervical lymphadenopathy are much less common.1,2,4 In one review, 20.6% of gonococcal tonsillitis presented with whitish-yellow exudate.4

Diagnosis of gonococcal tonsillitis requires a positive culture from the pharynx.1 A sexual history is essential in guiding the decision to test, and an appropriate sexual history includes not only identifying high-risk behaviors, but also the sites of sexual contact.2 Penile-oral contact is the single highest risk factor for gonococcal tonsillitis.1,2,4

Treatment should include intramuscular ceftriaxone plus doxycycline or azithromycin to prevent resistance and also because co-infection rates of chlamydia are as high as 20% to 54%.1,2 Treatment also entails counseling the patient on appropriate condom use for all sexual contact, treatment of partners, and avoidance of all sexual contact until treatment has been completed and symptoms have resolved.1,2

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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