Abstract
Background Paradoxical reaction after the initiation of tuberculosis treatment is defined as increased inflammation following effective antimycobacterial treatment. This is a phenomenon that can severely complicate a patient’s recovery, potentially leading to further morbidity and residual deficits. Paradoxical reaction remains poorly understood regarding its pathophysiology and management. Only a limited number of reports look critically at the available therapeutic options, with evidence of the efficacy of prednisolone therapy being primarily limited to extrapulmonary PR only.CaseWe describe two HIV negative patients who were admitted to our department with pulmonary tuberculosis, presenting with inflammatory patterns attributable to PR and their response to adjunctive steroid therapy.Discussion and ConclusionsThe presented cases further highlight the need for immunological studies and randomized trials for corticosteroid therapy are needed to better understand this phenomenon as well as provide an evidence-base for anti-inflammatory treatment. Furthermore, by means of this case series, we are also able to highlight the potential variability in the symptomatology of the lesser known PR phenomenon, in which we observed a hypotensive shock-like syndrome not previously described in literature.
Highlights
Mycobacterium tuberculosis (Mtb) continues to be a daunting threat despite highly effective and standardized antimicrobial treatment [1]
We report their response to adjuvant corticosteroid therapy via clinical observation and radiographic imaging
Corticosteroids have been in use to manage a variety of forms of extrapulmonary TB [8, 9]
Summary
Mycobacterium tuberculosis (Mtb) continues to be a daunting threat despite highly effective and standardized antimicrobial treatment [1]. Chest X-rays (see Fig. 1 below) showed infiltrates in both lungs He was anemic (Hb 6.2 mmol/L) with MCV 75.4 fL; C-reactive protein (CRP) was elevated 73 mg/L; leukocyte count 11 × 109/L and 14.1 × 1 09/L the day after admission. He was started on HRZE combination therapy; sputum cultures later showed fully susceptible Mtb. Vitamin supplementation included pyridoxine and thiamine, targeting the patient’s alcohol-related nutritional deficiencies. The added corticosteroid could eventually be tapered over a 3 month period (Fig. 3), in which he showed gradual improvement, with a mild tachycardia (approximately 100 bpm) persisting for a month following prednisolone’s cessation before stabilizing His sputum cultures remained negative and his body weight increased, while CRP gradually declined to below 20 mg/L. Given our patient’s unsatisfactory rate of progress throughout his admission, an extended 9 month anti-tuberculosis therapy regimen was implemented, the remainder of which was continued on an outpatient basis using DOT
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