Paradoxical long segment myelitis in miliary pulmonary tuberculosis

Abstract

A 32-year female presented with weakness of both lower limbs with bladder bowel involvement of 1-month duration. She was bedridden for 10 days. She was diagnosed with pulmonary tuberculosis and was on anti-tubercular therapy (ATT) for last 1 and half months. Cough and fever subsided but paraparesis with bladder bowel involvement occurred on ATT. Her routine blood parameters were normal. The chest X-ray shows bilateral miliary shadows. MRI spine shows long segment myelitis involving cervical and dorsal spinal cord with dural enhancement. MRI brain shows meningeal enhancement with multiple small tuberculomas. CSF shows 80 cells, 75% lymphocytes, 3725 mg% protein and 29 mg% sugar (corresponding blood sugar 97 mg%). Anti-nuclear antibodies and extractable nuclear antigen panel was negative. Aquaporin 4 antibodies report is awaited. Paradoxical worsening and dissemination in whole body is a common occurrence in miliary tuberculosis. Simultaneous involvement may be due to hematogenous spread. On the other hand, paradoxical reaction is not uncommon and warrant addition of steroid and evaluation for drug resistance. Our patient improved partially with steroid administration and continuation of ATT. We recommend screening of whole body for tuberculosis in cases with miliary pulmonary involvement.