We present a case of 54 years-old female with clinical features of acute tonsillitis with subsequent acute cervical lymphadenitis. Despite an appropriate empirical usage of antibiotics and other medications for a week, she complaint persistent symptoms. On the meticulous examinations, we could not find any abnormalities in the nasopharynx, hypopharynx except slightly asymmetrically bulged left side palatine tonsil. On the computed tomography scan, mild enhancement of left palatine tonsil without mass-like contour and ipsilateral multiple enlarged cervical lymph nodes with few intranodal necrotic changes were identified. Fine needle aspiration cytology on the cervical lymph nodes revealed just a necrotic debris. For differential diagnosis from underlying hidden malignancies with consideration of refractory inflammation despite of antibiotics usage, tonsillectomy with excisional lymph node biopsy were performed. And the patient was diagnosed as Diffuse large B cell lymphoma on the final pathologic report. We would like to demonstrate the diagnostic challenges in such a rare condition and emphasize the importance of differentiating malignant lymphoma from an acute infectious disease