Tuberculous Tonsillitis in a Patient Treated with an Anti-TNF Agent

Tuberculosis remains a concern in patients receiving anti-TNF therapy as these individuals have a higher incidence of extrapulmonary and disseminated tuberculosis. Tuberculous tonsillitis is an unusual presentation of extrapulmonary tuberculosis, which is diagnosed mostly in immunodeficient patients. We report the case of a 33-year-old woman, diagnosed with Behçet’s syndrome, immunosuppressed with adalimumab, cyclosporine and prednisolone. She had odynophagia for 2 weeks, fever and a hypertrophied, ulcerated left tonsil. A tonsil biopsy revealed a granulomatous inflammatory process. Ziehl-Neelsen staining was positive for acid-fast bacilli. The chest x-ray revealed a milliary pattern. Gastric juice was positive for Mycobacterium tuberculosis complex DNA. A diagnosis of tonsillar and pulmonary tuberculosis was established. This case report highlights the low threshold for a tuberculosis diagnosis in unusual locations in patients treated with anti-TNF therapy. LEARNING POINTS: Tuberculosis is a concern in patients receiving anti-TNF therapy as these individuals have a higher incidence of disseminated and extrapulmonary tuberculosis despite previous screening and treatment of latent disease. Tuberculous tonsillitis is a rare presentation of extrapulmonary tuberculosis and is thought to occur mostly in immunodeficient patients. Tonsillar tuberculosis commonly presents with sore throat and cervical lymphadenopathy which with abnormal tonsillar findings (such as ulcerations, masses and white patches) makes the differential diagnosis with other tonsillar infections or neoplasms challenging.