Gonococcal tonsillar infection in a female sex worker

Abstract

Gonorrhea is a common sexually transmitted disease that can be seen worldwide. Gonorrhea usually presents with the genital disorder. Nevertheless, rare clinical manifestation can also be seen. Here, the authors would like to present the case of a female prostitute presenting with repeated tonsillitis and finally diagnosed for gonococcal tonsillar infection. In the present day, there are a variety of sexual preferences and sexual intercourse that might result in unexpected clinical problems. Asking for the unusual oral sex history should be included in the history taking of the patients with recurrent pharyngitis and tonsillitis.

INTRODUCTION

Sexually transmitted disease (STD) is an important medical problem and is still an important public health problem in several countries. There are several STDs such as gonorrhea. Gonorrhea is a common STD that can be seen worldwide. This problem can be seen worldwide. Gonorrhea usually presents with genital disorder. The genitalia discharge is the common presentation of gonorrhea.[1]

Nevertheless, rare clinical manifestation can also be seen. For example, the infection might cause joint or ocular problems. Furthermore, it can cause other rare clinical presentations that the practitioner might not recognize it. Here, the authors would like to present the case of a female prostitute presenting with repeated tonsillitis and finally diagnosed for gonococcal tonsillar infection.

CASE REPORT

The patient is a 23-year-old female presented with acute tonsillitis. The patient has no personal illness and no drug allergy. Throat examination reveals red enlarged tonsils with exudate (the patient did not allow taking a photo of her throat).

The patient has a history of repeated visits to the physicians for more than ten times per year with the same problem of acute tonsillitis. In each previous visit, the patient received penicillin as the antibiotic for the treatment, and the clinical problem was resolved, but the recurrence occurred within a few weeks.

The patient consulted with the physician in charge, who is a family physician, and gave the history that she was a prostitute and has to perform oral sexual intercourse with many different males. Nevertheless, she has no history of sexually transmitted infection, and her annual blood check, according to the legal regulation for the prostitute, for HIV serology and VDRL was negative. Furthermore, her annual gynecological examination result is within the normal limit. The differential diagnosis of recurrent tonsillitis in this patient is Group A beta-hemolytic Streptococcus pyogenes infection that requires microbiological examination for discrimination. In this case, the tonsil and throat swab were done, and the microbiological study revealed gonorrhea infection. The patient was treated with dual-therapy regimen with single-dose ceftriaxone intramuscular injection and single dose 1 g oral azithromycin according to the 2015 STDs Treatment Guidelines of CDC (https://www.cdc.gov/std/tg2015/gonorrhea.htm). Her clinical symptoms disappeared within 1 week. In this case, health education on safe sex was also given to the patient. However, the patient lost follow-up, and it cannot verify the success and impact of health education. Whether there is any impact on her profession, a prostitute is still questionable.

DISCUSSION

This is an interesting case of a rare presentation of gonorrhea. Gonococcal tonsillar infection is an uncommon form of gonorrhea and is usually related to oral sexual intercourse.[1] In a case with urogenital gonorrhea, the tonsillar infection is an important hidden problem.[2] In the report by Bro-Jorgensen and Jensen,[2] gonococcus organism could be seen in 1 of 49 cases with gonorrhea.[2] This problem can be sporadically seen worldwide. The case might present with only tonsillitis or with other organ involvements.[3] The sexual transmission of the gonococcus due to oral sexual intercourse is the cause of gonococcal tonsillitis. As noted by Balmelli and Günthard, “gonococcal tonsillitis should be included in the differential diagnosis of tonsillitis in sexually active patients.[1]” As the patient might have repeated sexual contact, the recurrence is possible. In a case series, 4 from 27 cases with tonsillar gonorrhea have recurrent tonsillitis.[4] Nevertheless, there is no report on the exact recurrence rate. The patient can present with simple exudative tonsillitis with or without fever and lymphadenopathy. Some patients might have disseminated gonococcal infection.[3] The routine culture is the way for the diagnosis.[5] In the present study, the patient presents a classical symptom of bacterial tonsillitis. The interesting is the observation of repeated frequent acute tonsillitis. In the present case, the patient gave a history of prostitution occupation and oral sexual practice. Here, it can suggest that the physician should aware of gonococcal tonsillitis in any patients with repeated frequent acute tonsillitis. The careful history taking and investigation are needed. Although the case report does not add any new findings or observations on atypical clinical presentations on the gonococcal tonsillar infection, it can bring us some considerations. First, in the present day, there are a variety of sexual preferences and sexual intercourse that might result in unexpected clinical problems. Asking for the unusual oral sex history should be included in history taking of the patients with recurrent pharyngitis and tonsillitis. Second, history taking on the occupation of the patient might give a clue for the diagnosis of a hidden problem. In the case of gonococcal tonsillar infection, a greater concern should be given in the area where the prostitute is a common occupation (such as in Indochina). Of interest, in India, there is no report on the case with gonococcal tonsillar infection, which might reflect that this problem is neglected. The prevalence of disease and relationship to the number of prostitutes in that area is an interesting topic for further study.

REFERENCES