“My symptoms have returned,” the 32-year-old woman wrote to her brother. “I woke up with a swollen tonsil and I have a hard time swallowing.” Her brother, nine years older than her and a doctor, sat up in bed. It was 10 p.m. on the West Coast, where he was, and 1 a.m. in Boston, where his sister lived.

A couple of weeks earlier, her sister, a self-described germaphobe, had sent her a message saying her throat hurt. He had returned from a trip to Taiwan two weeks earlier and, a day or two later, woke up with some pain when swallowing. It was just the right side. When he looked at his mouth in a mirror, he saw that his throat was red and that his tonsil was large and swollen toward the center.

The first few days, he alternated doses of paracetamol and ibuprofen, and that helped. But the pain returned as soon as the medicine wore off. In the end, he went to the MIT Health Center, where he was a graduate student. She was seen by a medical assistant, who listened to her concerns and examined her throat. He took a sample to test for strep. The results came in a few minutes: negative.

It was probably a virus, he told her, and he should get better in a few days. He prescribed six days of a steroid called methylprednisolone to relieve the symptoms.

Hearing this, his brother became a little worried. Steroids would reduce inflammation and pain, but they do so by suppressing the immune system. He didn’t say anything. He was a hospitalist, working with inpatients, and had not worked in an outpatient setting for more than a decade. Perhaps that was the usual practice.

By the second day, the swelling and pain had disappeared, and the woman felt completely recovered, she said with joy. He finished the treatment and forgot about his throat problem.

But two or three days after finishing the steroids, he woke up with the same horrible sore throat. If anything, swallowing hurt a little more. And his right tonsil was red again and swollen towards the center.

Back to square one

He returned to the health center that same morning. The doctor was kind and attentive as he asked her the now familiar list of questions: she had no fever, no cough, no runny nose, no wheezing, no difficulty breathing. Just a very intense sore throat. Eating was almost impossible, and talking was pure torture. He saw that her throat was red and her right tonsil was swollen, just like two weeks before. He gave her a rapid strep test and, once again, it came back negative. This time the doctor ordered a throat culture, to make sure he didn’t need antibiotics. But she agreed with the medical assistant who had treated her earlier that it was probably a virus. He sent her to the lab for blood tests and advised her to continue treating the pain and drink plenty of water. She gorged on paracetamol and ibuprofen, but the pain did not subside. So he contacted his brother again.

“Are you done with the steroids?” he responded by message. “Yes, a couple of days ago; he said it probably wore off and that’s why the pain came back,” she replied. “It sounds logical,” he agreed. But that night, the young woman began to feel worse. He had chills. His whole body hurt. He took ibuprofen and then Tylenol. “We really should be grateful for our health,” he wrote to his brother. His sister didn’t say those things, so he picked up the phone and called her. When she didn’t answer, he called her on FaceTime.

“You don’t realize how much you swallow until it hurts like this,” she told him. His voice sounded strange, almost unrecognizable. “Do you have a fever?” he asked her. She didn’t know. He had her take her temperature. He heard the thermometer beep: 38 degrees Celsius, she told him. He was concerned that she had even a low-grade fever after taking ibuprofen and Tylenol. “Hold the camera so I can see the inside of your throat,” he said. It was just as she had described; the back of his throat was very red, and the tonsil and surrounding area were swollen, but only on the right side.

His brother was worried. With his red, swollen throat and that strangely muffled voice, he suspected he might have a peritonsillar abscess: a pus-filled pocket near his tonsils that he only knew about because he had read about the condition. It was too late to call an infectious disease specialist friend who might know more, so he turned to an online AI resource called OpenEvidence. He entered his symptoms and asked the specialized chatbot for possible diagnoses. First on the bot’s list was the peritonsillar abscess. Among the symptoms she described were a severe unilateral sore throat and a “hot potato voice,” as if the patient was speaking with a mouth full of potatoes. He also said that most cases of this disorder were treated on an outpatient basis. Even so, his illness seemed to have progressed very quickly.

“I think you should go to the ER,” he told her. That morning, the doctor had only seen a swollen tonsil and red throat, but now, 12 hours later, his brother could see that the entire right side of his throat was not only red, but swollen. She didn’t want to go. I had an appointment with the ENT doctor the next day. And I hated going to the emergency room. But if the infection was spreading so quickly, it could be dangerous to wait until the next morning. The inflammation could even block your airways. In the end he agreed to go.

Treatment and relief

It was 1:30 a.m. when a physician assistant treated her in the emergency room at Massachusetts General Hospital. His temperature and heart rate were normal, but the right side of his face seemed a little swollen. The tonsil was enlarged and appeared dotted with small spots of white discharge. The tonsillar pillars—the structures that support and surround the tonsil—were also red and so swollen that they almost hid the gland. The uvula, the teardrop-shaped tissue that hangs at the back of the throat, was a normal size and was not deviated to the left, as occurs in some serious infections. The medical assistant gently pressed the flesh with a tongue depressor. If it gave more, that would suggest an occult abscess. It had to be checked by otolaryngologists, he said. But first they would do a CT scan.

The image showed a pocket of fluid, the size of a large grape, next to the swollen tonsil. The radiologist thought it was a peritonsillar abscess. The ENT doctor reviewing the images on his screen remotely disagreed, saying the infection was in the tonsil itself. In any case, she would need to be evaluated in person by an ENT doctor. He was given a dose of a powerful steroid and, for the first time in days, the pain subsided.

At 8 the next morning, the young woman was transferred from the emergency room to the Mass Eye and Ear clinic. A resident doctor examined her and, after looking at her throat, immediately agreed with the radiologist: it was undoubtedly a peritonsillar abscess. And it had to be drained. The patient accepted the intervention. A few minutes later, they gave him a couple of lidocaine injections. The surgeon brought his sterilized instruments. The patient took a look and then decided she didn’t want to look.

He closed his eyes as the surgeon put his hand in his mouth. He didn’t feel anything. He had a brief metallic taste of blood until the surgeon sprayed salt water into his mouth through an aerosol. And that was it.

As soon as he could, he looked at the incision in the mirror. It was huge. The surgeon prescribed 10 days of antibiotics and assured him that he would be cured in a week or so. And so it was. I spoke to your brother recently. Doctors are not supposed to treat family members. Did he think the fact that she was his sister influenced how he viewed her case?

Maybe, he told me. He was worried about her in a different way because she was his sister. On the other hand, who, if not a sister, would have given him this kind of detailed information? And the possibility of an infection progressing as quickly as seemed to be the case for her would have motivated her recommendation to go to the emergency room, regardless of who had requested it. With any patient, he told me, it is always better to be safe than sorry.