Tubercular meningitis with therapeutic paradox
Tubercular meningitis is not so uncommonly associated with clinical deterioration while on treatment, which is observed 2-3months after starting the treatment, sometimes upto 18 months. A 12 year old boy presented with fever and cough of 1 week duration, evaluated and diagnosed to have disseminated tuberculosis. Anti-tubercular therapy was started. While on treatment child was apparently normal for about 2 months and then developed signs of meningo-encephalitis. On evaluation with MRI imaging, found to have new onset multiple subcentimetric ring enhancing lesions in both cerebral hemispheres suggestive of tuberculomas. This is due to improved delayed type of hypersensitivity observed after starting treatment for active tubercular infection. This condition responds well to steroids and does not warrant change of drug regimen.
Abduljabbar M, Paradoxical response to chemotherapy for intracranial tuberculoma: two case reports from Saudi Arabia. Journal of Tropical Medicine and Hygiene 1991, 94: 374-3
Prakash Rao G, Rajendra Nadh B, Hemaratnam A et al. Paradoxical progression of tuberculous lesions during chemotherapy of central nervous system tuberculosis. Journal of Neurology 1995, 83: 359-362.
Gupta M, Bajaj BK, Khawaja G. Paradoxical response in patients with CNS tuberculosis. J Assoc Physicians India 2003;51:257-260.
Breen RA, Smith CJ, Bettinson H, et al. Paradoxical reactions during tuberculosis treatment in patients with and without HIV co-infection. Thorax 2004;59:704-707.
Shelburne SA III, Hamill RJ. The immune reconstitution inflammatory syndrome. AIDS Rev 2003;5:67-79.
Afghani B and Lieberman JM. Paradoxical enlargement or development of intracranial tuberculmas during therapy: Case report and review. Clinical infectious diseases 1994, 19: 1092-1099