Tonsillitis Caused by Vomiting in a Patient with Bulimia Nervosa: A Case Report and Literature Review

A 32-year-old lady presented to our ENT service with worsening tonsillitis. This was one of multiple attacks; all of which had all followed periods of self-induced vomiting due to the patient suffering with bulimia nervosa. Here we present the first ever case report of such a case of tonsillitis and a review of the literature of otolaryngology manifestations and complications of bulimia nervosa. 1. Introduction Bulimia nervosa is a psychological disorder involving cyclical purging following eating. Otolaryngological manifestations centre on sialomegaly, oral disease, and the complications of self-induced purging. We discuss a case of vomiting-induced tonsillitis in a bulimia nervosa sufferer and review the published literature of otolaryngology associations with bulimia nervosa. 2. Case Presentation A 32-year-old lady presented to our emergency ENT service complaining of a sore throat. This had developed over a 7-day period and was associated with a fever and odynophagia of solids and liquids. Her symptoms had failed to improve despite a four-day course of benzylpenicillin 500？mg qds and a two-day course of metronidazole 400？mg tds. The patient reported no past medical history but revealed that she had suffered from bulimia for 15 years although general practitioner review had declined further contact with the psychiatric services because of difficult previous experiences with them. She described fortnightly purging following eating during the previous 6 months, which was followed by episodes of tonsillitis. She used no regular medications. ENT examination revealed bilaterally enlarged, erythematous tonsils, and jugulodigastric lymphadenopathy. No peri-tonsillar abscess was present. Ear examination and nose examination were normal. Blood testing was normal throughout. IgM screen was negative. The patient was admitted to our ENT service for intravenous antibiotic therapy. The patient declined followup for consideration of a tonsillectomy as she was moving to a different region. The patient was advised to contact her new local otolaryngology service for tonsillectomy consideration. 3. Discussion Bulimia nervosa is a psychological eating disorder involving cyclical purging following eating. Up to 95% of sufferers are women [1]. The peak incidence is in young women [1]. The disorder was formally identified in 1979, although a previous case had been reported as early as the nineteenth century [2, 3]. Cyclical purging following eating was commonplace in Roman civilisation. Salivary gland enlargement was the earliest reported otolaryngology manifestation of