> THE PATIENT 35-year-old-woman > THE CLINICAL QUESTION Is tonsillectomy an appropriate treatment modality for this adult patient's refractory group a β-hemolytic streptococcal pharyngitis, in light of her history of recurrent infections?

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> THE CASEA 35-year-old woman sought care for a fever and sore throat that she'd had for 4 days. She denied symptoms of cough, rhinorrhea, or sputum production.The patient's medical history included severe recurrent streptococcal pharyngitis as a child and teenager. At the age of 17, she developed a fever of 105° F with associated delirium, dysphagia, nausea, and vomiting, and missed several days of school. She also lost 82 pounds, developed oral thrush, and continued to feel fatigued for approximately a year. After her primary care physician noted a heart murmur on physical exam, she was sent for echocardiography and diagnosed with rheumatic fever secondary to streptococcal pharyngitis.Eighteen years (and numerous streptococcal infections) later, the patient was at our facility and we were ordering a rapid antigen detection test (RADT) for her current illness. The throat specimen was positive for group A β-hemolytic streptococcus (GAS). The patient's 8-year-old daughter also had a sore throat, fever, and positive RADT; her symptoms resolved with oral amoxicillin for 10 days. The patient's husband was also treated successfully with oral amoxicillin/clavulanate for 10 days for similar symptoms. The patient herself, however, was unsuccessfully treated with oral amoxicillin 500 mg twice daily for 7 days.She was then given oral amoxicillin/clavulanate 875 mg twice daily for 14 days, but received no relief. Even after receiving clindamycin 600 mg twice daily for 10 days, she had minimal relief and remained positive for GAS on repeat RADT. It was at this point that tonsillectomy was considered as a possible treatment modality for her refractory GAS pharyngitis.▪ The patient consented to the procedure and underwent a tonsillectomy. She has remained asymptomatic for 2 years and there have been no reported outbreaks of GAS infection in her household.

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