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These forms often succeed the previous one and are characterized by the presence of bright-red tonsils with purulent exudate: of yellowish gray, with spots or streaks, thin and brittle, easily dissociated, and not exceeding the tonsillar area. Examination of the pharynx shows false membranes with a pearly sheen that can extend beyond the tonsil region onto the cion (uvula palatinae), soft palate, and its arcus palatini. It is necessary to think particularly of infectious mononucleosis (Epstein-Barr virus) when angina is prolonged and associated with diffuse adenopathies, splenomegaly, marked asthenia, and purpura of the soft palate.
Diphtheria, formerly a classic etiology, has become rare in France ever since compulsory vaccination. Other possible but rare causes include staphylococcus, streptococcus, pneumococcus, or other mononuclear syndromes (CMV and HIV). Vesicular angina is characterized by exulceration of the epithelial layer, followed by an elusive vesicular rash on the tonsils and arcus palatini.

Herpes angina has a very similar symptomatology and is caused by Group A coxsackie viruses, occurring mainly in young children. This angina, caused by anaerobic germ infections, occurs in patients in a very fragile state: diabetes, kidney failure, and blood diseases. However, one must always keep this etiology in mind when confronted with rapidly extensive pseudomembranous angina, associated with unusual pallor and fatigue. Syphilitic serology testing confirms the diagnosis (initial testing and at Day 15): VDRL is positive 2-3 weeks following chancre, TPHA is positive 10 days after chancre, FTA is positive very early (7 to 8 days) and has excellent specificity, whereas the Nelson test is positive much later at 1 month. In addition to viruses and GAS angina, the causal agent may be hemolytic streptococcus other than Group A, staphylococcus, pneumococcus, Pasteurella tularensis (tularemia), or Toxoplasma gondii (toxoplasmosis). With a growing population of transplant patients, two factors guide the diagnosis, notably the lack of vaccination as well as return visits to an endemic area.

Penicillin therapy is the standard treatment, such as Extencillin (2.4 MU at 8-day intervals) or Biclinocillin. Isolation (for 1 month), diphtheria serotherapy (10,000-20,000 U in children; 30,000-50,000 U in adults), and screening for Corynebacterium diphteriae must be implemented immediately in order to avoid malignant forms, previously of very poor prognosis.

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