Paradoxical Reaction of Multiple Cerebral Tuberculomas

Abstract

A 28-year-old woman was admitted to the hospital because of fever, night sweats, and cough. Chest radiographic findings were suggestive of miliary tuberculosis. Acid-fast bacilli were observed in a bronchoalveolar lavage fluid specimen, and cultures were positive for Mycobacterium tuberculosis, which is susceptible to all drugs. Antituberculous treatment was initiated, with progressive improvement. The patient was readmitted to the hospital 5 weeks later because of progressive dizziness and headache. Remarkably, fundoscopic examination revealed presence of papilledema. Magnetic resonance imaging revealed multiple small enhancing lesions (approximately 2 mm in diameter) in the brain with perifocal edema in both the supratentorial and the infratentorial compartments. Corticosteroid therapy was added to the medical regimen on the basis of intracranial edema and the presumed diagnosis of paradoxical reaction of brain tuberculomas. Corticosteroid therapy was given for 3 months, with tapering of the dose. After a 9-month course of antituberculous treatment, the patient recovered uneventfully. Clinical deterioration during antituberculous therapy in patients whose symptoms have initially improved is known as a paradoxical reaction. This condition could be caused by worsening of preexisting tuberculous lesions or development of new lesions not attributable to the normal disease course in a patient whose condition initially improved with antituberculous treatment and in whom paradoxical reaction occurred about 1 month after initiation of therapy. It has been proposed that paradoxical reaction is the result of an excessive inflammatory response in the context of immune reconstitution and increased antigen exposure after administration of antituberculous therapy. No changes in or discontinuation of antituberculous treatment is necessary when paradoxical reaction occurs. Some studies suggest that early recognition and treatment with systemic corticosteroid therapy might result in a more favorable outcome.