Paradoxical progression of tuberculous lesions during chemotherapy of central nervous system tuberculosis

Rao, Ganesh; Nadh, B. Rajendra; Hemaratnan, A.; Srinivas, T. V.; Reddy, P. Madhusudhana

doi:10.3171/jns.1995.83.2.0359

Cited by 62 publications

(35 citation statements)

References 9 publications

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“…INH and pyrazinamide (PZA) are used frequently as effective chemotherapeutic agents against CNS tuberculosis because of their high blood-brain barrier permeability. 13) A regimen of antituberculous chemotherapy should continue until clinical and laboratory effectiveness is achieved for 52 weeks (12 months) or more, and consist of at least two agents to overcome drug resistance. Addition of a third agent for the initial 8 to 24 weeks is also recommended.…”

Section: Discussionmentioning

confidence: 99%

Spinal Intramedullary Tuberculoma Requiring Surgical Treatment-Case Report-

Miyamoto

Sasajima

Owada

et al. 2003

Neurol. Med. Chir.(Tokyo)

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A 71-year-old male presented with multiple central nervous system tuberculomas including spinal intramedullary tuberculoma manifesting as occipitalgia and left hemiparesis. He had received medical treatment for lung and testis tuberculosis. Magnetic resonance imaging revealed an intramedullary lesion at the C-2 level as well as multiple small extramedullary and intracranial lesions. His neurological symptoms gradually worsened despite intensive antituberculous therapy. The C-2 intramedullary lesion responsible for left hemiparesis was surgically extirpated. Postoperatively, his neurological symptoms improved gradually, and no recurrence was evident at the resected site. Surgical intervention is mandatory in patients with intramedullary tuberculoma if neurological symptoms deteriorate or lesions enlarge despite continuous antituberculous therapy.

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Section: Discussionmentioning

confidence: 99%

Spinal Intramedullary Tuberculoma Requiring Surgical Treatment-Case Report-

Miyamoto

Sasajima

Owada

et al. 2003

Neurol. Med. Chir.(Tokyo)

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“…Paradoxical worsening can occur in both HIVuninfected 1 10 13 15 and infected 2 4 5 8 11 12 patients starting TB therapy and is generally attributed to a reconstituting host delayed hypersensitivity response with increased exposure to mycobacterial antigens under bactericidal therapy. Recrudescence of fever, enlarging adenopathies, worsening pulmonary infiltrates, pleural effusion, ascites, new or enlarging parenchymal central nervous system lesions and superior vena cava syndrome have all been reported 1 2 4 5 8 10-13 15 . We are unaware of previous reports of paradoxical responses uncovering meningeal disease in HIV-infected patients.…”

Section: Discussionmentioning

confidence: 99%

Paradoxical reaction to the treatment of tuberculosis uncovering previously silent meningeal disease

Eyer-Silva

Pinto

Arabe

et al. 2002

Rev. Soc. Bras. Med. Trop.

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The development of paradoxical clinical worsening following initiation of tuberculosis treatment may complicate the clinical course of both HIV-infected and uninfected patients. We report a severe manifestation of the so called paradoxical reaction to the treatment of tuberculosis that unmasked previously silent meningeal disease in a 34-year-old HIV-infected male patient. Key-words: AIDS. Antiretroviral therapy. Paradoxical reaction. Tuberculosis. Tuberculous meningitis.Resumo O desenvolvimento de piora clínica paradoxal como resposta ao início do tratamento da tuberculose pode complicar a evolução de pacientes com e sem infecção pelo HIV. Apresentamos uma grave manifestação da chamada reação paradoxal ao tratamento da tuberculose, que revelou doença meníngea previamente silenciosa em um paciente HIV-positivo de 34 anos. Palavras-chaves: AIDS. Meningite tuberculosa. Reação paradoxal. Terapia anti-retroviral. Tuberculose. Concomitantly treating active tuberculosis (TB) and HIV infection is a challenging task. There is a great potential for adverse effects and clinically significant pharmacological interactions. The development of paradoxical clinical worsening on TB treatment may further complicate patient management. We report a life-threatening manifestation of paradoxical worsening following TB treatment initiation in an antiretroviral (AR)-experienced patient. CASE REPORTA 34-year-old HIV-infected male patient with previous experience to the HIV reverse transcriptase inhibitors zidovudine and didanosine, to the HIV protease inhibitor saquinavir and on Pneumocystis carinii prophylaxis developed an enlarging cervical mass associated with a 2-month history of fever, weigh loss and malaise. At that point laboratory evaluation showed mild anemia (hemoglobin 11,3mg/dL), 60 CD4 cells/mm 3 and a plasma HIV viral load of 25,000 copies/mL (all viral load measurements were performed using the nucleic acid sequence-based amplification assay). Chest X-ray was normal. He had never had an opportunistic disorder but was treated for pleural TB during early adulthood. Histopathology disclosed TB lymphadenitis and Mycobacterium tuberculosis grew from the node aspirate. Rifabutin (as an alternative rifamycin to be combined with a protease inhibitor) at a dose of 150mg/day, isoniazid, pyridoxine and pyrazinamide were started and the AR regimen was changed to stavudine, lamivudine and indinavir. He significantly improved and remained well until ten weeks later when recrudescence of fever and severe headache developed. Signs of meningeal irritation were absent, as were cognitive, behavioral or focal neurologic abnormalities. Computed tomography of the brain was normal. Cerebrospinal fluid (CSF) studies revealed marked pleocytosis (220 cells/mm 3 , 71% polymorphonuclear, 29% mononuclear cells), glucose 52mg/dL and elevated protein (156mg/dL) and were negative for acid-fast bacilli, mycobacterial cultures, other infectious agents and neoplastic cells. Ophthalmologic examination disclosed TB choroidal nodules (previous evalu...

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“…The yield of AFB culture from CSF can be increased by centrifuging the CSF, preparing thick smears from cobweb and increasing the examina on me. The solu on to this dilemma of paradoxical response with nega ve laboratory support, lies in close monitoring of pa ent with con nua on of drugs already in use with addi on of steroid, increasing the dose of drugs already in use and/or addi on of second line ATT 17,18,19,20 .…”

Section: Discussionmentioning

confidence: 99%

Neurological Worsening in a Child of Miliary Tuberculosis with Neuro-Tuberculosis on Anti Tubercular Treatment

Arora

Narang

Dhillon

2016

J. Nepal Paedtr. Soc.

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A seven and half year old male child presenting with pyrexia of unknown origin was diagnosed to be a case of miliary tuberculosis. Neuroimaging revealed multiple discrete ring as well as nodular enhancing lesions indicative of tuberculomas. After the initial response to ATT along with systemic steroids the child again presented with severe headache along with vomiting towards the end of intensive phase. Repeat neuroimaging showed appearance of new lesions with perilesional edema. Child was started again on systemic steroids and Streptomycin was added to the anti tubercular regimen, to which the child responded well.

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Paradoxical progression of tuberculous lesions during chemotherapy of central nervous system tuberculosis

Cited by 62 publications

References 9 publications

Spinal Intramedullary Tuberculoma Requiring Surgical Treatment-Case Report-

Spinal Intramedullary Tuberculoma Requiring Surgical Treatment-Case Report-

Paradoxical reaction to the treatment of tuberculosis uncovering previously silent meningeal disease

Neurological Worsening in a Child of Miliary Tuberculosis with Neuro-Tuberculosis on Anti Tubercular Treatment

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