# EBV-Tonsillitis with superinfection involving Staphylococcus aureus and Prevotella Oris leading to life-threatening bleeding in a 13-year-old girl: a case report

## TL;DR

A 13-year-old girl with EBV tonsillitis developed severe complications from a bacterial superinfection, leading to life-threatening bleeding and requiring emergency treatment.

## Contribution

This case report highlights the rare and severe complications of EBV infection combined with bacterial superinfection in an immunocompetent adolescent.

## Key findings

- The patient developed necrotizing oropharyngitis and bilateral carotid artery hemorrhage during EBV infection.
- Bacterial superinfection by Prevotella oris and MSSA was identified as a contributing factor to severe complications.
- Multidisciplinary management was crucial for stabilizing the patient and enabling recovery.

## Abstract

Viral infections of the upper airways are common in children and adolescents, often presenting with mild symptoms and typically resolving without the need for hospitalization. Epstein-Barr virus (EBV), a gammaherpesvirus, can cause diverse clinical syndromes and transient immune dysregulation, potentially predisposing to bacterial superinfection.

We report a 13-year-old girl with critical upper airway obstruction due to necrotizing ulcerative oropharyngitis in the context of an EBV infection, with superinfection by Prevotella oris and methicillin-sensitive Staphylococcus aureus (MSSA) isolated from operative tissue specimens. Within a very short time, the patient developed EBV-associated nephritis and pneumonia, severe sepsis, and acute respiratory distress syndrome (ARDS). Extensive soft-tissue necrosis precipitated life-threatening hemorrhage from the right external carotid artery followed by a second hemorrhage on the left, requiring coil embolization and ligation. Additionally, the patient experienced neurological complications due to thiamine deficiency, contributing to a complex and prolonged recovery process. Despite the severity of her illness, multidisciplinary management enabled stabilization and eventually discharge to a rehabilitation facility.

To our knowledge, fulminant necrotizing oropharyngitis with bilateral external carotid hemorrhage during acute EBV infection in an immunocompetent adolescent is exceedingly rare. This highlights the importance of considering anaerobic oral colonizers as potential pathogens in maxillofacial infections. Clinicians should reassess for bacterial superinfection when EBV courses are protracted or deteriorating.

The online version contains supplementary material available at 10.1186/s12887-025-06441-7.