A Rare Manifestation of Infectious Mononucleosis Tonsillitis

The purpose of this case report is to describe a rare case of infectious mononucleosis (IM) hemorrhagic tonsillitis. Our patient presented with acute tonsillitis complicated by spontaneous tonsillar hemorrhage. This is a single case report with a literature review. A 19-year-old male presented to the emergency department with a 10-day history of worsening sore throat, recurrent fevers, malaise, and dysphagia to solids and liquids, as well as a three-day history of epistaxis and hemoptysis. He tested positive for Epstein-Barr virus and rhinovirus. On exam, a “hot potato” voice was noted along with bilateral tonsillar edema, erythema, and hypertrophy. Both tonsils with dry blood coating and no exudates were visualized. Computed tomography (CT) imaging of the neck demonstrated subcutaneous emphysema isolated to the tonsils. Treatment consisted of intravenous antibiotics and steroids, followed by an oral antibiotic, with subsequent full resolution of symptoms. This case illustrates a rare, severe manifestation of IM tonsillitis that radiographically can mimic other more severe soft-tissue neck infections on imaging, such as cervical necrotizing fasciitis. In patients presenting with hematemesis, hemoptysis, and/or epistaxis, along with tonsillar edema, erythema, and hypertrophy, a diagnosis of spontaneous hemorrhagic tonsillitis should be considered. The radiographic findings of soft-tissue emphysema in the deep spaces of the head and neck region may be seen in the setting of IM, mimicking other soft-tissue infections of the deep neck spaces.