CASE
A 6-year-old boy was seen initially in autumn with the complaint of foulsmelling breath and a fever. Because he had enlarged tonsils, his general practitioner (GP) diagnosed tonsillitis and prescribed an oral antibiotic. A few months later, the patient returned with the same complaint of bad breath, pallor, and poor appetite. His mother reported multiple episodes of tonsillitis, but a review of his medical records documented only two previous occurrences. The patient's tonsils were described as red and enlarged but without any signs of purulence. His GP prescribed an oral antifungal agent for possible oral candidiasis secondary to using a corticosteroid inhaler and an iron supplement. At the GP's recommendation, the patient saw his dentist, who found no cause for the foul breath and suggested that the patient see his GP again.
I met the patient 2 weeks later, when he presented with a 5-month history of foul breath. According to his mother, the condition had become a source of ridicule at school to the extent that he was not doing well with his studies, had been absent on several occasions, and was inattentive to his homework. The medical history was significant for tonsillitis, chickenpox, impetigo, an innocent heart murmur, and asthma. He was current on all childhood immunizations.
The patient was a healthy-appearing, afebrile boy in no acute distress. Examination of the oropharynx was unremarkable for tonsillar edema, erythema, purulence, foul breath, or periodontal disease. No cervical lymphadenopathy was detected. Purulent drainage coming from the left nares was accompanied by a fetid odor.
Click NEXT to find the true diagnosis.