Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
, 4 (8), 000690

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


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

Sara Ferreira et al. Eur J Case Rep Intern Med.


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.

Keywords: Tuberculous tonsillitis; adalimumab.

Conflict of interest statement

Conflicts of Interests: The Authors declare that there are no competing interests.


Figure 1
Figure 1
Hypertrophied left tonsil. (a) At admission. (b) After treatment initiation
Figure 2
Figure 2
Left tonsil histology. (a) Granulomatous inflammatory process with necrosis. (b) Higher amplification showing epithelioid granulomas with multinucleated giant cells and eosinophilic necrosis
Figure 3
Figure 3
Chest x-rays. (a) Before treatment, showing several small, and uniformly distributed, nodular opacities throughout both lung fields (milliary pattern). (b) After treatment initiation

Similar articles

  • Primary Tonsillar Tuberculosis - Case Report
    NC Balica et al. Rom J Morphol Embryol 60 (1), 267-271. PMID 31263855. - Case Reports
    We report the case of a 44-year-old male patient with tonsillar tuberculosis (TB) diagnosed in the Department of Ear, Nose & Throat (ENT), "Victor Babeş" University o …
  • Primary Tonsillar Tuberculosis
    S Sasikumar et al. BMJ Case Rep 2018. PMID 30249724. - Case Reports
    Upper aerodigestive tract involvement with tuberculosis is relatively rare and may be seen in up to 2% of patients with pulmonary tuberculosis. Isolated tonsil involvemen …
  • Clinical Aspects of Tonsillar Tuberculosis
    S Srirompotong et al. Southeast Asian J Trop Med Public Health 33 (1), 147-50. PMID 12118442.
    A clinical analysis of 6 patients with pathologically confirmed tonsillar tuberculosis was carried out retrospectively. The subjects comprised three men and three women, …
  • Tuberculous Tonsillitis
    O Celik et al. J Otolaryngol 24 (5), 307-9. PMID 8537992. - Review
    The epidemiology of tuberculosis has changed recently with an increasing incidence of unusual presentations. A case of tuberculous tonsillitis, which is a rare condition, …
  • Peritonsillar Abscess: Clinical Aspects of Microbiology, Risk Factors, and the Association With Parapharyngeal Abscess
    TE Klug. Dan Med J 64 (3). PMID 28260599. - Review
    PTA is a collection of pus located between the tonsillar capsule and the pharyngeal constrictor muscle. It is considered a complication of acute tonsillitis and is the mo …
See all similar articles


    1. Armuzzi A, Lionetti P, Blandizzi C, Caporali R, Chimenti S, Cimino L, et al. Anti-TNF agents as therapeutic choice in immune-mediated inflammatory diseases: focus on adalimumab. Int J Immunopathol Pharmacol. 2014;27:11–32. - PubMed
    1. Rifkin LM, Birnbaum AD, Goldstein DA. TNF inhibition for ophthalmic indications: current status and outlook. BioDrugs. 2013;27:347–357. - PubMed
    1. Nacci F, Matucci-Cerinic M. Tuberculosis and other infections in the anti-tumour necrosis factor-alpha (anti-TNF-α) era. Best Pract Res Clin Rheumatol. 2011;25:375–388. - PubMed
    1. Sutbeyaz Y, Ucuncu H, Murat Karasen R, Gundogdu C. The association of secondary tonsillar and laryngeal tuberculosis: a case report and literature review. Auris Nasus Larynx. 2000;27:371–374. - PubMed
    1. Carmona L, Gómez-Reino JJ, Rodríguez-Valverde V, Montero D, Pascual-Gómez E, Mola EM, et al. Effectiveness of recommendations to prevent reactivation of latent tuberculosis infection in patients treated with tumor necrosis factor antagonists. Arthritis Rheum. 2005;52:1766–1772. - PubMed

LinkOut - more resources