Cobblestone Throat in a Younger Patient Infected with the Omicron Variant of the SARS-CoV-2 Virus

Genki Inui Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan;
Department of Respiratory Medicine, National Hospital Organization Yonago Medical Centre, Tottori, Japan

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Katsuyuki Tomita Department of Respiratory Medicine, National Hospital Organization Yonago Medical Centre, Tottori, Japan

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Akira Yamasaki Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan;

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A 21-year-old woman without a history of tobacco use presented to the emergency department (ED) with a 1-day history of an acute scratchy throat and fever. She had an unremarkable past medical history. On physical examination, she had a blood pressure of 116/72 mmHg, a heart rate of 84 beats/minute, a body temperature of 37.6°C, a respiratory rate of 18 breaths/minute, and an oxygen saturation of 98% on room air. No lymphadenopathy was noted. Furthermore, no adventitious sounds were noted on chest auscultation. A Wi-Fi–based flexible endoscope revealed a strawberry-like rough surface, similar to a cobblestone appearance, of the posterior oropharynx (Figure 1). Laboratory examination showed a white blood cell count of 7,400 cells/μL (3,100–8,400), a lymphocyte count of 850 lymphocytes/μL (1,000–4,800), a C-reactive protein level of 1.6 mg/dL (0–0.3 mg/dL), a lactate dehydrogenase level of 349 U/L (120–220 U/L), a ferritin level of 184 ng/mL (20–250 ng/mL), and D-dimer levels of 0.5 μg/mL (0–1.0 μg/mL). Chest X-ray showed no evidence of pneumonia.

Figure 1.
Figure 1.

Cobblestone throat at the peritonsillar area on the right side (arrows).

Citation: The American Journal of Tropical Medicine and Hygiene 109, 2; 10.4269/ajtmh.22-0747

She claimed to have been exposed to people with known COVID-19 a few days earlier. The patient tested positive for SARS-CoV-2 via a revere transcription polymerase chain reaction (PCR) nasopharyngeal swab and was diagnosed with COVID-19 infection. This Omicron variant was confirmed by sequences performed as administrative medical examinations. Additional viral testing via PCR-based panel and streptococcal antigen testing was negative. She received a one-time dose of racemic epinephrine aerosol in the ED. Her symptoms improved 1 week later.

The Omicron strain, first discovered in November 2021, is reported to have a tendency to exhibit strong pharyngeal symptoms in young people.1 Although there are reports of severe epiglottitis,1 there are few reports of pharyngeal findings. In this case, we found cobblestone throat findings, and later confirmed similar findings in other COVID-19 cases (Figure 2).

Figure 2.
Figure 2.

Cobblestone throat of the posterior oropharynx in other COVID-19 cases.

Citation: The American Journal of Tropical Medicine and Hygiene 109, 2; 10.4269/ajtmh.22-0747

The differential diagnosis is influenza from the symptoms and pharyngeal findings. Influenza follicles resulting from influenza infection are well known as pharyngeal findings of viral infection.2 The short time from infection to onset is associated with the characteristic follicular formation that is shiny and tense.2 In this case, follicles with similar luster were observed, suggesting that the findings may have appeared as a result of the characteristics of the short viral replication time of the Omicron strain.3 The finding of cobblestone inflammation of the posterior pharynx in SARS-CoV-2 infection without concurrent influenza infection raises the possibility of a broader differential diagnosis when this physical examination finding is noted, and SARS-CoV-2 and influenza should be differentiated from one another via available diagnostic testing.

ACKNOWLEDGMENT

The American Society of Tropical Medicine and Hygiene has waived the Open Access fee for this COVID-19 article.

REFERENCES

  • 1.

    Piersiala K, Kakabas L, Bruckova A, Starkhammar M, Cardellars LO, 2022. Acute odynophagia: a new symptom of COVID-19 during the SARS-CoV-2 Omicron variant wave in Sweden. J Intern Med 292: 154161.

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    • Search Google Scholar
    • Export Citation
  • 2.

    Miyamoto A, Watanabe S, 2011. Posterior pharyngeal wall follicles as early diagnostic marker for seasonal and novel influenza. J Gen Med Fam Med 12: 5160.

  • 3.

    Hui KPY et al., 2022. SARS-CoV-2 Omicron variant replication in human bronchus and lung ex vivo. Nature 603: 715720.

Author Notes

Address corresponding to Akira Yamasaki, Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, 36-1 Nishimachi, Yonago 683-8504, Tottori, Japan. E-mail: yamasaki@tottori-u.ac.jp

Disclaimers: Written consent for publication was obtained from the patient.

Authors’ addresses: Genki Inui, Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan, and Department of Respiratory Medicine, National Hospital Organization Yonago Medical Centre, Tottori, Japan, E-mail: genki.inui@tottori-u.ac.jp. Katsuyuki Tomita, Department of Respiratory Medicine, National Hospital Organization Yonago Medical Centre, Tottori, Japan, E-mail: ktomita0223@gmail.com. Akira Yamasaki, Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan, E-mail: yamasaki@tottori-u.ac.jp.

  • Figure 1.

    Cobblestone throat at the peritonsillar area on the right side (arrows).

  • Figure 2.

    Cobblestone throat of the posterior oropharynx in other COVID-19 cases.

  • 1.

    Piersiala K, Kakabas L, Bruckova A, Starkhammar M, Cardellars LO, 2022. Acute odynophagia: a new symptom of COVID-19 during the SARS-CoV-2 Omicron variant wave in Sweden. J Intern Med 292: 154161.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Miyamoto A, Watanabe S, 2011. Posterior pharyngeal wall follicles as early diagnostic marker for seasonal and novel influenza. J Gen Med Fam Med 12: 5160.

  • 3.

    Hui KPY et al., 2022. SARS-CoV-2 Omicron variant replication in human bronchus and lung ex vivo. Nature 603: 715720.

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