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Persistent tonsillitis may become another symptom of covid-19 and immunonutrition supports healing process in patient with history of tonsillitis: a case report

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Al Mukhlas Fikri at Universitas Singaperbangsa Karawang
Al Mukhlas Fikri
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A health survey supervisor aged 26 years old with normal body temperature conducted a PCR swab test as research protocol at the end of data collection. He already felt unwell three days before the PCR swab test. The test showed positive for COVID-19. He self-isolated and consumed nutritional supplements, including B vitamins, vitamin C, vitamin D, zinc, propolis, and probiotics. Persistent tonsillitis with odynophagia was found as the primary symptom. Other symptoms like sore throat, hot sensation in feet and hands, headache and mucus production behind the nose appeared only for one or two days. Fever, dry cough, and diarrhea were not found. On day 8 of confirmation, the PCR swab test showed a negative result. Even several days after the negative result, an enlarged tonsil was still observed, but without odynophagia. We propose persistent tonsillitis should be regarded as a new symptom of COVID-19, and immuno-nutrition supports the healing process in a patient with a tonsillitis history.
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Berita Kedokteran Masyarakat
(BKM Journal of Community Medicine and Public Health)
Volume 37 Number 2, 2021
Page 43-45
DOI: 10.22146/bkm.v37i2.1567
Submitted:
February 18th, 2021
Accepted:
February 25th, 2021
Published:
February 27th, 2021
1Department of Nutrition,
Faculty of Health Sciences,
University of Singaperbangsa
Karawang, Karawang,
Indonesia
2Department of Community
Nutrition, Faculty of Human
Ecology, IPB University, Bogor,
Indonesia
*Correspondence:
mukhlas.fikri@fikes.unsika.ac.
id
Persistent tonsillitis may become another
symptom of COVID-19, and immuno-nutrition
supports the healing process in patients with a
history of tonsillitis: a case report
Al Mukhlas Fikri1, Ahmad Sulaeman2, Eka Andriani1
Abstract
At the end of data collection, a health survey supervisor aged 26 years old
with normal body temperature conducted a PCR swab test as a research
protocol. He already felt unwell three days before the PCR swab test. The test
showed positive for COVID-19. He self-isolated and consumed nutritional
supplements, including B vitamins, vitamin C, vitamin D, zinc, propolis, and
probiotics. This case found persistent tonsillitis with odynophagia as the
primary symptom. Other symptoms like sore throat, hot sensation in feet and
hands, headache and mucus production behind the nose appeared only for
one or two days. No fever, dry cough, and diarrhea were found. On day 8 of
confirmation, the PCR swab test showed a negative result. Even several days
after the negative result, an enlarged tonsil was still observed, but without
odynophagia. We propose that persistent tonsillitis should be regarded as a
new symptom of COVID-19, and immuno-nutrition supports the healing
process in a patient with a history of tonsillitis.
Keywords: COVID-19; immuno-nutrition; SARS-CoV-2; tonsillitis
INTRODUCTION
WHO, on March 13, 2020, declared the COVID-19
outbreak as a pandemic. Severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), which is the
cause of COVID-19, has infected over 75 million people
(around 10% of the total global population) till the end
of 2020. New confirmed cases remain persistently high.
The broad clinical spectrum of the diseases, ranging
from fever, sore throat, dry cough, headache, and
diarrhea, to severe pneumonia, causes difficulty in the
early stage in identifying and controlling the spread of
COVID-19 [1,2]. Current knowledge showed no
association between COVID-19 and tonsillitis. However,
one study in Pakistan reported tonsillitis as the
manifestation of COVID-19 in a 24-year female [3].
Thus, we aimed to report similar findings.
Meanwhile, immuno-nutrition has been proposed
to take a significant role in the prevention and
treatment of COVID-19. Micro-nutrient deficiency is
associated with a high risk of viral infection and its
severity [4]. Several vitamins and minerals serving as
immunomodulators like vitamins A, B, C, and D, zinc,
selenium, magnesium, and copper, potentially
contribute to COVID-19 prevention and treatment [5].
Besides presenting a new COVID-19 symptom, this
report aimed to show the role of immuno-nutrition in
the healing process of COVID-19 patients.
CASE PRESENTATION
A 26-year-old male patient came to the Regional
Public Hospital of South Sumatra for a PCR swab test on
December 3, 2020, with a normal body temperature
(36,5oC). He was a supervisor of a health survey in
Palembang city. To follow survey protocols, he got
43
Berita Kedokteran Masyarakat, Volume 37 (2) 2021: 38-42
nasopharyngeal and oropharyngeal PCR swab tests. On
November 28, 2020, the last day of data collection, he
supervised the enumerators in several census blocks
following strict protocols. After the previous
supervision, he self-isolated at a hotel and minimized
physical contact. On November 30, 2020, he started
feeling unwell, headaches, and odynophagia. He has a
history of tonsillitis. The symptoms continued until the
day of the PCR swab test.
Table 1. Developing symptoms of a 26-year-old male
patient with COVID-19
Estimated
Exposure
Day
Day of
Confirmation
1
-
2
-
3
-
4
-
5
-
6
1
7
2
8
3
9
4
10
5
11
6
12
7
13
8
(+) shows positive PCR swab test result
(–) shows negative PCR swab test result
We estimated SARS-CoV-2 had infected the patient
on November 28, 2020, when he supervised the data
collection process by considering minimum physical
contact before and after the supervision. The patient
experienced mild symptoms during the infection
period, where the symptoms appeared on day three
after the estimated day of infection. Table 1 shows the
symptoms suffered by a patient with a primary sign of
swollen tonsil. For a total of 9 days, the patient had
odynophagia. Even several days after the PCR swab test
showing a negative result, an enlarged tonsil was still
found but without odynophagia (Figure 1). Other
symptoms developed, including sore throat, hot
sensation on hands and feet, headache, and mucus
production behind the nose. However, the patient had
those symptoms only in one or two days. The patient
did not have a fever, dry cough, and diarrhea.
Daily nutritional supplements during self-isolation
could include 1500 mg vitamin C, 400 IU vitamin D, 2
mg vitamin B1 mononitrate, 2 mg vitamin B2, 15 mg
nicotinamide, 2 mg vitamin B6 HCl, 5 mg calcium
pantothenate, 20 mg zinc, five drops of propolis, and
probiotic (Lactobacillus casei 6.5 x 109). The patient ate
a balanced diet, rich in fruits and vegetables, and
actively did an exercise for 10 min consisting of
push-up, sit-up, plank, and elbow-to-knee crunches. On
day 8 of confirmation, the PCR swab test showed a
negative result. In addition, strong social support from
social media encourages him to face the disease.
DISCUSSIONS
The present report shows tonsillitis was
persistently found in a patient with COVID-19.
Tonsillitis is an inflammation caused by viruses or
bacteria, causing swelling and redness of the tonsils
leading to odynophagia [6]. Common pathogens include
Streptococcus bacteria, Epstein-Barr virus, hepatitis A,
rubella, and HIV. While no study stated SARS-CoV-2
causing recurrent tonsillitis, this report describes how
tonsillitis appeared along with novel coronavirus
infection. Tonsillitis typically lasts 3 or 4 days, but the
present patient had tonsillitis for more than one week.
In addition, odynophagia disappeared along with the
negative PCR test result. Our report supports the
previous case report that also found tonsillitis as a
manifestation of COVID-19 [3].
SARS-CoV-2 can replicate in the upper respiratory
tract actively [7]. COVID-19 is detected through the
nasal and oropharyngeal swabs. A tonsil is a set of
lymphoid organs at the rear of the throat and plays an
essential role in the immune system. High viral load in
the upper respiratory tract may induce tonsillar
inflammation either by specific infection in the tonsil
or the effect of general inflammation to attack
SARS-CoV-2 in the respiratory tract. However, the
precise mechanism needs further investigation.
Recently, Anderson and Paterek [8] believe that
coronavirus is the pathogen causing tonsillitis. After
several days of a negative result of the PCR swab test,
there was a possibility of tonsillar hypertrophy in the
patient and possibly because of prolonged tonsillitis
during the infection of SARS-CoV-2 [6].
44
Berita Kedokteran Masyarakat, Volume 37 (2) 2021: 38-42
Figure 1. Tonsillar enlargement during and after
infection of COVID-19. Tonsillitis showing redness
during infection of COVID-19 (A); Tonsillar
enlargement after PCR swab test showed negative
result (B)
Meanwhile, the present report also shows
immuno-nutrition supports the healing process. The
patient ordinarily had mild symptoms. The peak period
only led to three days, including swollen tonsils with
odynophagia, hot sensation in hands and feet, nasal
congestion, and mucus production behind the nose.
The patient did not develop fever, dry cough, diarrhea,
and anosmia commonly found in COVID-19 in the
patient. Even delirium, recently confirmed as the
symptom of COVID-19, was also not seen, probably
because of strong social support. B-complex vitamins,
vitamin C, vitamin D, and zinc are proposed to
positively affect a patient with COVID-19 through
immunomodulatory action [5]. Propolis and probiotics
also possess an immunomodulatory property that
supports our immune system to suppress viral
infections like SARS-CoV-2 [9,10]. Hence,
immuno-nutrition may contribute to a negative PCR
swab test result on day 8 of confirmation.
This report is limited for not providing
biochemical or radiology data. In addition, the
symptoms of COVID-19 greatly vary between patients,
hence difficult to conclude only from one case.
Therefore, these findings need further investigation.
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Gresele, P., Marchetti, M., et al. (2020). COVID-19
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2. Larsen, J.R., Martin, M.R., Martin J.D., Kuhn, P.,
and Hicks, J.B. (2020). Modeling the onset of
symptoms of COVID-19. Front. Public Health. 8,
473. doi: https://doi.org/10.3389/fpubh.2020.00473
3. Fatima, K., and Naqvi, S.G.Z. (2020). Tonsillitis as a
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4. Gorji, A., and Ghadiri, M.K. (2021). The potential
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https://dx.doi.org/10.1016%2Fj.nut.2020.111047
5. Gasmi, A., Tippairote, T., Mujawdiya, P.K., Peana,
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Trigona spp. extract in a mouse model. J. Agric.
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45
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