Leukemic Tonsillitis Presenting as Sore Throat

Many patients with hematologic malignancies are initially seen in the primary care setting. Here we demonstrate such a case in a young woman who presented with a sore throat. She was referred to a tertiary care center because of abnormal blood cell counts and was then rapidly treated with resolution of symptoms.

THE CASE

A previously healthy 21-year-old woman presented with a sore throat of a few weeks’ duration. Her primary care provider prescribed an antibiotic; however, the symptoms did not resolve. A complete blood cell count was ordered, which revealed a significantly elevated white blood cell count (WBC) of 78,000/µL. She was hospitalized for further evaluation.

Physical examination results were unremarkable except for 1-cm postauricular and anterior and posterior cervical lymph nodes. The throat showed bilaterally enlarged tonsils without exudates and no evidence of mucositis (Figure 1).

A throat culture was negative for streptococci and other bacteria. The WBC count revealed 91% blasts with Auer rods. Other laboratory results included hemoglobin, 11.4 g/dL; platelets, 65,000/µL; and lactate dehydrogenase, 1281 IU/L (upper limit of normal, 618 IU/L).

She was started on hydroxyurea 3 g/d and allopurinol 300 mg/d until further evaluation revealed acute myeloid leukemia without maturation (AML M1) with inversion (16) cytogenetics. Within a few hours after admission, the patient reported enlargement in the size of her tonsils, which was associated with difficulty in speaking. She was treated with 1 g cytarabine followed by the FLAG (fludarabine, cytarabine, granulocyte colony-stimulating factor) induction regimen—fludarabine 30 mg/m²/d for
5 days and cytarabine 2 g/m²/d for 5 days.

She had an immediate improvement in throat symptoms, and at 3 weeks she had resolution of her enlarged tonsils (Figure 2), reduction of marrow blasts to 5% or less, and blood recovery. She was then treated with 6 further consolidation courses. The patient is now in a continuous complete response at 9 months.

DISCUSSION

Sore throat is a common presenting symptom in primary care practice. Lymph node or tonsil enlargement can also occur as a direct involvement of extramedullary tissues with leukemic blasts. Treatment with chemotherapy can lead to rapid resolution of symptoms.