Tonsillitis is routinely managed in primary care, yet immunosuppressed patients may present with atypical or persistent symptoms that demand closer attention. Methotrexate, widely used for rheumatoid arthritis, predisposes patients to iatrogenic immunodeficiency–associated lymphoproliferative disorders (IA-LPDs), particularly Epstein–Barr virus–positive forms. For family physicians, recognizing when a common complaint deviates from its usual course is essential to prevent diagnostic delay.A 70-year-old woman with seropositive rheumatoid arthritis on long-term methotrexate presented with two months of recurrent sore throat and fever initially resembling bacterial tonsillitis. Examination showed erythematous tonsils with purulent exudate, and CT revealed bilateral tonsillar necrosis with extensive necrotic lymphadenopathy in the cervical, mediastinal, and axillary regions. She was referred to otolaryngolotist for operative evaluation. Bilateral tonsillectomy was performed due to concern for malignancy or deep infection. Histopathology demonstrated a polymorphic EBV-positive lymphoproliferative disorder with Hodgkin-like features, consistent with IA-LPD. Despite delayed wound healing and persistent ulceration, withdrawal of methotrexate led to gradual and complete clinical improvement.Bilateral necrotic tonsillitis as the initial manifestation of methotrexate-associated EBV-positive IA-LPD is extremely rare. This case broadens the recognized clinical spectrum of IA-LPDs and highlights diagnostic challenges in primary care.Persistent tonsillar necrosis, unusual lymphadenopathy, or poor response to standard therapy in immunosuppressed patients should prompt early imaging and referral. Withdrawal of methotrexate may induce complete regression in EBV-positive IA-LPDs, reinforcing the value of timely recognition in primary care.Although tonsillectomy provided a definitive diagnosis, image-guided core needle or lymph node biopsy could be considered as less invasive alternatives when LPD is suspected. Necrotic tonsils and widespread lymphadenopathy initially mimicked infection, delaying recognition of methotrexate-related EBV-positive IA-LPD. The absence of EBV viral load and clonality testing limits further classification, and the long-term recurrence risk remains uncertain.Persistent tonsillar necrosis or atypical lymphadenopathy in immunosuppressed patients should prompt early imaging and specialist referral. Clinicians should consider IA-LPD in methotrexate-treated patients, as timely cessation of immunosuppression may allow full remission and prevent overtreatment.