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Hermans SM, Akkerman OW, Meintjes G, Grobusch MP. Post-tuberculosis treatment paradoxical reactions. Infection 2024:10.1007/s15010-024-02310-0. [PMID: 38955990 DOI: 10.1007/s15010-024-02310-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
Paradoxical reactions (PR) to tuberculosis (TB) treatment are common during treatment, but have also been described after treatment. A presentation with recurrent signs or symptoms of TB after cure or completion of prior treatment needs to be differentiated between microbiological relapse and a paradoxical reaction. We searched all published literature on post-treatment PR, and present a synthesis of 30 studies, focusing on the epidemiology, diagnosis and management of this phenomenon. We report an additional case vignette. The majority of studies were of lymph node TB (LN-TB), followed by central nervous system TB (CNS-TB). A total of 112 confirmed and 42 possible post-treatment PR cases were reported. The incidence ranged between 3 and 14% in LN-TB and was more frequent than relapses, and between 0 and 2% in all TB. We found four reports of pulmonary or pleural TB post-treatment PR cases. The incidence did not differ by length of treatment, but was associated with younger age at initial diagnosis, and having had a PR (later) during treatment. Post-treatment PR developed mainly within the first 6 months after the end of TB treatment but has been reported many years later (longest report 10 years). The mainstays of diagnosis and management are negative mycobacterial cultures and anti-inflammatory treatment, respectively. Due to the favourable prognosis in LN-TB recurrent symptoms, a short period of observation is warranted to assess for spontaneous regression. In CNS-TB with recurrent symptoms, immediate investigation and anti-inflammatory treatment with the possibility of TB retreatment should be undertaken.
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Affiliation(s)
- Sabine M Hermans
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- University Medical Centre Groningen, TB Centre Beatrixoord, University of Groningen, Groningen, The Netherlands
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin P Grobusch
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Tropical Medicine, University of Tuebingen, Tübingen, Germany
- Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon
- Masanga Medical Research Unit (MMRU), Masanga, Sierra Leone
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2
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Skouvig Pedersen O, Barkholt TØ, Horskær Madsen S, Rudolf F. Tuberculosis immune reconstitution syndrome (TB-IRIS) followed by recurring lymphadenitis up to 8 years post-antituberculous treatment. BMJ Case Rep 2024; 17:e259211. [PMID: 38885999 DOI: 10.1136/bcr-2023-259211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
We present the case of a patient with HIV and tuberculosis (TB) coinfection who initially developed paradoxical TB immune reconstitution inflammatory syndrome (TB-IRIS) post-antituberculous treatment and post-antiretroviral therapy initiation. Despite being managed effectively, lymphadenitis recurred as many as three times over the course of several years. Due to consistent culture-negative lymph node biopsies, the recurring lymphadenitis was eventually deemed inflammatory rather than microbiological recurrences. Cessation of anti-TB treatment led to symptom remission followed by a long asymptomatic period, corroborating the immunological nature of the episodes. However, 5 and 6 years after cessation of anti-TB treatment, respectively, lymphadenitis returned. In both instances, her symptoms regressed without treatment with anti-TB drugs. This case underscores the complexities of managing TB-IRIS and the necessity of differentiating between paradoxical TB-IRIS and other paradoxical reactions for appropriate treatment decisions. Recognition of such distinctions is crucial in guiding effective therapeutic interventions in TB-HIV coinfection scenarios.
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Affiliation(s)
- Ole Skouvig Pedersen
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Trine Ørhøj Barkholt
- Department of Nuclear Medicine & PET-Centre, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Frauke Rudolf
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
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3
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Azoulay LD, Houist AL, Feredj E, Vindrios W, Gallien S. [Paradoxical tuberculosis reaction]. Rev Med Interne 2024; 45:279-288. [PMID: 38267320 DOI: 10.1016/j.revmed.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
Paradoxical tuberculosis reaction is defined as the aggravation of lesions present at diagnosis or the development of new lesions under anti-tuberculosis treatment, after exclusion of other alternate causes. It affects 5 to 30% of tuberculosis patients, with a variable prevalence depending on the site of infection and the clinical background. The diagnosis of paradoxical reaction is one of elimination, and requires having ruled out therapeutic failure, notably linked to poor compliance and/or to the presence of mycobacterial antibiotic resistance. The severity of paradoxical tuberculosis reaction lies in its neurological impairment. Despite its clinical importance, the mechanisms involved remain poorly understood and its management is not consensual. Corticosteroids are the cornerstone in the medical management. The role of anti-TNF agents, currently proposed in cases of corticodependence or corticoresistance, remains to be properly defined.
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Affiliation(s)
- L-D Azoulay
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France.
| | - A-L Houist
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - E Feredj
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - W Vindrios
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - S Gallien
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
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4
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Lai KKH, Cheng JKH, Ko CKL. Paradoxical ocular tuberculosis-associated immune reconstitution inflammatory syndrome in a patient with systemic lupus erythematosus. J Fr Ophtalmol 2024; 47:103989. [PMID: 37919146 DOI: 10.1016/j.jfo.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Kenneth K H Lai
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong.
| | - Jacky K H Cheng
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
| | - Callie K L Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
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Robert M, Mageau A, Gaudemer A, Thy M, Peiffer Smadja N, de Lastours V, De Broucker T, Papo T, Goulenok T, Sacré K. Incidence, risk factors and treatment of central nervous system immune reconstitution inflammatory syndrome in non-HIV patients with tuberculous meningitis: a multicentre observational study. Intern Med J 2024; 54:802-808. [PMID: 38064539 DOI: 10.1111/imj.16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 10/15/2023] [Indexed: 05/18/2024]
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) affecting the central nervous system (CNS) is associated with poor outcomes. AIMS To report on risk factors for CNS-IRIS following tuberculous meningitis (TBM) in HIV-negative patients. METHODS In this retrospective multicentre study, all HIV-negative adult patients admitted between 2003 and 2021 with microbiologically proven TBM were included. The primary outcome measure was IRIS onset over follow-up. Characteristics of patients who developed IRIS were described. Factors associated with IRIS were identified using a multivariable logistic regression procedure. RESULTS Fifty-six patients (33.0 (27.0-44.3) years, 39 (69.6%) men) with microbiologically proven TBM were studied. All patients received antituberculosis treatment and 48 (n = 48/56; 85.7%) steroids at TBM diagnosis. During a median follow-up of 18.0 (12.0-27.3) months, IRIS occurred in 28 (n = 28/56, 50.0%) patients, at a median time of 2.0 (1.0-3.0) months after antituberculosis treatment was started. IRIS involved the CNS in all but one case. Imaging revealed new (n = 23/28, 82.1%) and/or worsening (n = 21/28; 75.0%) of previously recognised lesions. Multivariable analysis showed that meningeal enhancement on brain magnetic resonance imaging (MRI) (odds ratio (OR): 15.3; 95% confidence interval (CI): (1.19-1193.5)) at TBM diagnosis and high blood albumin level (OR: 1.21; 95% CI: (1.02-1.60)) were associated with the occurrence of CNS-IRIS during follow-up. CONCLUSION CNS-IRIS following TBM in non-HIV patients appears frequent and severe. Meningeal enhancement on brain MRI at tuberculosis diagnosis is a risk factor for CNS-IRIS.
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Affiliation(s)
- Marie Robert
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Arthur Mageau
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Augustin Gaudemer
- Service de Radiologie, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Michael Thy
- Service de Maladies infectieuses, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Nathan Peiffer Smadja
- Service de Maladies infectieuses, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Victoire de Lastours
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Thomas Papo
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
- Centre de Recherche sur l'Inflammation, INSERM UMR1149, CNRS ERL8252, Faculté de Médecine site Bichat, Laboratoire d'Excellence, Inflamex, Université de Paris, Paris, France
| | - Tiphaine Goulenok
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Karim Sacré
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
- Centre de Recherche sur l'Inflammation, INSERM UMR1149, CNRS ERL8252, Faculté de Médecine site Bichat, Laboratoire d'Excellence, Inflamex, Université de Paris, Paris, France
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6
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Kalita J, Shukla R, Pandey PC, Singh V, Haldar R, Misra UK. mRNA profiling of cytokines to understand paradoxical response in HIV-uninfected tuberculous meningitis. Tuberculosis (Edinb) 2024; 144:102463. [PMID: 38101267 DOI: 10.1016/j.tube.2023.102463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
Paradoxical reaction (PR) in tuberculous meningitis (TBM) is a major management issue. We report mRNA profiling of cytokines to understand PR in HIV-uninfected TBM patients. 72 patients with TBM were included, and their clinical, MRI, and mRNA profiling of tumor necrosis factor (TNF) α, interleukin (IL) 6, IL10 and interferon (IFN) γ genes in the peripheral blood mononuclear cells were done at admission and 6 weeks of antitubercular treatment. Cytokine profiling was done using reverse transcriptase polymerase chain reaction. PR was defined if repeat MRI at 6 weeks revealed new or increase in exudates, tuberculoma, hydrocephalus or infarctions. Outcome was defined at 6 months using modified Rankin Scale (mRS), and categorized as death, poor and good. 44 (61.1 %) patients had PR, and 28 (38.9 %) had paradoxical tuberculoma (PT). The expression of IL6 and TNFα genes were higher in PR and PT groups. Stage of meningitis and hydrocephalus at admission predicted PR. Patients with PR and PT had more frequently poor outcome. About three-fifth HIV-uninfected TBM patients have PR and two-fifth have PT. Paradoxical reaction is associated with higher expression of IL6 and TNFα. Patients with severe meningitis with hydrocephalus develop PR more frequently.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India.
| | - Ruchi Shukla
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Prakash C Pandey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radio diagnosis Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Rudrashish Haldar
- Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India
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7
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Samad M, Dallevet CA, Tandjaoui-Lambiotte Y, Bourgarit A, Jaquet P. Spectacular Improvement of Paradoxical Reaction in Tuberculosis after Tumor Necrosis Factor-Alpha Antagonist Therapy. Cureus 2023; 15:e50596. [PMID: 38222121 PMCID: PMC10788139 DOI: 10.7759/cureus.50596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/16/2024] Open
Abstract
We report the case of a 42-year-old immunocompetent Indian patient presenting with miliary tuberculosis complicated by respiratory failure requiring intubation. Conventional quadritherapy was initiated for wild-type Mycobacterium tuberculosis. On day 29 of antibiotic treatment, persistent fever and neurological deterioration prompted the diagnosis of multiple brain and medullary tuberculomas, some surrounded by edema. Laboratory investigations ruled out meningitis and subtherapeutic drug concentrations. To enhance cerebrospinal fluid penetration, ethambutol was replaced with levofloxacin on day 30, and rifampicin doses were increased to 30 mg/kg. Dexamethasone was introduced on day 30 to address the paradoxical response to antituberculosis therapy, but neurological deterioration persisted, leading to hemiparesis and coma, with concurrent development of acute respiratory distress syndrome. As salvage therapy, an anti-tumor necrosis factor agent, infliximab (IFX), was administered on day 40. Rapid clinical improvement was observed, marked by awakening and subsequent weaning from respiratory ventilation just eight days after the first IFX infusion. The patient was discharged from the intensive care unit 10 days post-IFX initiation, with steroids discontinued one month after IFX introduction. Both antituberculosis treatment and IFX infusions (seven in total) were maintained for one year. Clinical and radiological evaluation at one year demonstrated complete clinical and radiological recovery.
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Affiliation(s)
- Myriam Samad
- Pulmonology & Infectious Diseases Department, Delafontaine Hospital, Saint-Denis, FRA
| | | | | | - Anne Bourgarit
- Internal Medicine, Jean Verdier Hospital AP-HP, Bondy, FRA
| | - Pierre Jaquet
- Intensive Care Unit, Delafontaine Hospital, Saint-Denis, FRA
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8
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Tran D, Patel K, Ashfaq A, Lyons B. Disseminated Miliary and Intestinal Tuberculosis Mimicking Inflammatory Bowel Disease. Cureus 2023; 15:e50002. [PMID: 38186434 PMCID: PMC10767475 DOI: 10.7759/cureus.50002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
The hematogenous dissemination of Mycobacterium tuberculosis (M. tb) is commonly via the pulmonary system. Less commonly, ingestion of M. tb can lead to primary intestinal tuberculosis (TB), often misdiagnosed as inflammatory bowel disease (IBD). In extremely rare cases, the dissemination can involve cardiac infiltration/tuberculoma. One such case involves a 21-year-old man from Guatemala who spoke a rare dialect of Spanish with nonspecific complaints and an abdominal CT scan showing terminal ileum thickening suggestive of Crohn's disease (CD). A colonoscopy revealed ileitis and tissue biopsy showed granulomatous inflammation with a positive acid-fast bacillus (AFB) stain and positive blood cultures isolated for TB. Chest CT angiography (CTA) also revealed miliary nodules and a right atrial mass was confirmed with cardiac MRI. Viral serology revealed chronic hepatitis B virus (HBV) co-infection, but the patient was HIV-negative. Anti-tubercular therapy (ATT) with rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE), in addition to tenofovir, was initiated, followed by a complicated hospital stay including rifampin-induced bone marrow suppression. Ultimately, he was discharged on isoniazid, pyrazinamide, ethambutol, levofloxacin, and entecavir. Intestinal TB can be misdiagnosed as IBD with the administration of steroids, potentially worsening infection. A systemic approach to clinical investigation with a thorough history using medical translators can lead to early diagnosis and treatment of intestinal and disseminated TB.
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Affiliation(s)
- Danny Tran
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Kunaal Patel
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Areeba Ashfaq
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Brittany Lyons
- Internal Medicine, Trident Medical Center, Charleston, USA
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Rai DK, Kant S, Gupta VB. Paradoxical reaction in peripheral lymph node tuberculosis: a review for its prevalence, clinical characteristics, and possible treatment. Monaldi Arch Chest Dis 2023. [PMID: 37789748 DOI: 10.4081/monaldi.2023.2625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/27/2023] [Indexed: 10/05/2023] Open
Abstract
The paradoxical reaction (PR) is a transient worsening following tuberculosis treatment and it is not uncommon in lymph node tuberculosis (LNTB). PR in LNTB maybe wrongly considered as treatment failure or relapse. This review was undertaken to address various aspects of PR associated with lymph node tuberculosis prevalence, underlying mechanism, clinical pattern, predictors, and possible treatment in an immunocompetent individual. A literature review was performed using various databases (PubMed, Scopus, Science Direct, and Google Scholar) to identify relevant articles for review. The prevalence of paradoxical reactions associated with LNTB varies from as low as 13.3% to as high as 35.3% PR may occur during antitubercular treatment or be reported even after completion of treatment called post-therapy PR. An onset of PR may occur within a month of therapy to even 12 months from the initiation of an anti-tubercular drug. Delayed hypersensitivity reaction and reduction in immune suppression is believed to be possible mechanism leading to a paradoxical reaction. PR in LNTB is characterized by either progression of pre-existing nodal enlargement or formation of abscess, sinus formation, or appearance of new nodal enlargement or rarely extra-nodal involvement. PR is a diagnosis of exclusion and may show granuloma, positive AFB smear, or positive GeneXpert but AFB culture is always negative. Younger age, lymph node size of equal to or more than 3 cm, female gender, unilateral lymphadenopathy, and those with positive AFB on initial examination are predictors for PR in peripheral LNTB. The majority of PR in LNTB have a mild course and are generally self-limited.
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Affiliation(s)
- Deependra Kumar Rai
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna.
| | - Surya Kant
- Department of Respiratory Medicine, King George Medical University, Lucknow.
| | - Vatsal Bhushan Gupta
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna.
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10
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Jansem P, Siranart N, Pongpitakmetha T, Anukoolwittaya P. Tuberculous Meningitis with the Soap Bubble Appearance Abscess Formation Resulting from a Paradoxical Reaction during Treatment in an Immunocompetent Host. Ann Neurol 2023; 94:803-805. [PMID: 37548474 DOI: 10.1002/ana.26759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Priabprat Jansem
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanakit Pongpitakmetha
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Chula Neuroscience Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Prakit Anukoolwittaya
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Chula Neuroscience Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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11
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Hashiba T, Sugahara M, Ota Y, Kaseda K, Kashiwagi Y, Nakamura M, Shinohara T, Ikeda M, Okugawa S, Sugimoto K, Sasaki K, Hamasaki Y, Yamada D, Kume H, Moriya K, Nangaku M. Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome. Intern Med 2023; 62:2559-2564. [PMID: 36642517 PMCID: PMC10518560 DOI: 10.2169/internalmedicine.0898-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023] Open
Abstract
Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.
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Affiliation(s)
- Toyohiro Hashiba
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Mai Sugahara
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yui Ota
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Ken Kaseda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yusuke Kashiwagi
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Motonobu Nakamura
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Takayuki Shinohara
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Mahoko Ikeda
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Kazuma Sugimoto
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kenichi Sasaki
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Yoshifumi Hamasaki
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Daisuke Yamada
- Department of Urology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Haruki Kume
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
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12
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Shimoda M, Yoshiyama T, Tanaka Y, Morimoto K, Okumura M, Kodama T, Yoshimori K, Ohta K. Characteristics of pleural effusion due to paradoxical response in patients with pulmonary tuberculosis. J Infect Chemother 2023; 29:890-894. [PMID: 37244351 DOI: 10.1016/j.jiac.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Patients with pulmonary tuberculosis may present with deterioration of pleural effusion during anti-tuberculosis therapy, referred to as a paradoxical response (PR), with some patients requiring additional intervention. However, PR may be confused with other differential diagnoses, and the predictive factors for recommending additional therapies are unknown. Therefore, this study aimed to reveal useful information for the diagnosis and intervention of PR. METHODS Data from human immunodeficiency virus-negative patients with tuberculous pleurisy (n = 210), including 184 patients with pre-existing pleural effusion and 26 patients with PR at Fukujuji Hospital, were retrospectively collected from January 2012 to December 2022 and compared. Furthermore, patients with PR were divided into the intervention group (n = 9) and the no intervention group (n = 17) and were compared. RESULTS Patients in the PR group had lower pleural lactate dehydrogenase (LDH) (median 177 IU/L vs. 383 IU/L, p < 0.001) and higher pleural glucose (median 122 mg/dL vs. 93 mg/dL, p < 0.001) levels than those in the preexisting pleural effusion group. Other pleural fluid data were not significantly different. Patients in the intervention group had a shorter duration from the initiation of anti-tuberculosis therapy to the development of PR than patients in the no intervention group (median 19.0 days [interquartile range (IQR): 18.0-22.0] vs. median 37.0 days [IQR: 28.0-58.0], p = 0.012). CONCLUSION This study demonstrates that, apart from lower pleural LDH and elevated pleural glucose levels, PR presents with similar features to preexisting pleural effusion and that patients who develop PR faster tend to require intervention.
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Affiliation(s)
- Masafumi Shimoda
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan.
| | - Takashi Yoshiyama
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Yoshiaki Tanaka
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Kozo Morimoto
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Masao Okumura
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Tatsuya Kodama
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Kozo Yoshimori
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
| | - Ken Ohta
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose, Tokyo, Japan
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Kaya A, Altınkaynak M, Keskin F, Özdemir G, Kaya SY, Mert A. Paradoxical psoas and subcutaneous abscesses developing on anti-tuberculous treatment: A case report and literature review. J Natl Med Assoc 2023; 115:392-397. [PMID: 37308345 DOI: 10.1016/j.jnma.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/08/2023] [Accepted: 05/15/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Abdurrahman Kaya
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey.
| | - Merve Altınkaynak
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey
| | - Feyza Keskin
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey
| | - Gülhan Özdemir
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey
| | - Sibel Yıldız Kaya
- Department of Infectious Diseases, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Turkey
| | - Ali Mert
- Infectious Diseases and Clinical Microbiology, Faculty of Medicine, İstanbul Medipol University, Turkey
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14
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Misra UK, Warrier S, Kalita J, Tripathi A, Kumar S. Treatment response and complications during management of Pott's spine. J Neuroimmunol 2022; 373:577979. [PMID: 36270077 DOI: 10.1016/j.jneuroim.2022.577979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
The global incidence of TB in 2016 was 10.4 million and India accounts for a quarter of the global burden of TB. It is estimated that there are 2.79 million people with TB in India. About 10% of extra pulmonary TB involves bone and joints. Spinal TB accounts for half the cases of skeletal TB. The incidence of spinal TB is 1-4% of total TB cases, then it is estimated that only in India approximately 60,000 spinal TB cases exist. To report the pattern of recovery and predictors of outcome of Pott's spine. The intervention comprised of four drug antitubercular treatment, rest, immobilization, and ultrasonography or computerized tomography guided aspiration or biopsy as indicated outcome measures were six months Nurick grade, and mRS and complications like drug induced hepatitis (DIH) and paradoxical worsening. Seventy-three patients with Pott's spine, median age 36 (11-73) years, 32 (43.8%) females were included. The neurological signs were present in 44 (64.4%) patients. At six months, median Nurick grade improved from 4 to 2 and;and 70% patients had a good outcome as defined by mRS.The predictors of poor outcome were weight loss, non-ambulatory state on admission and paradoxical worsening. It is concluded that neurological involvement in Pott's spine was present in 64% patients, paradoxical worsening (deterioration in symptoms after one month of ATT) in 11% and DIH in 16%. Weight loss, non-ambulatory state on admission and paradoxical worsening predicted poor outcome.
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Affiliation(s)
- Usha K Misra
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India.
| | - Siddharth Warrier
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India
| | - Jayantee Kalita
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India
| | - Abhilasha Tripathi
- Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India
| | - Sunil Kumar
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India
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15
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Yamamoto M, Manabe T, Yokokawa K, Tsuzaka K, Yamada M, Miyanaga R, Saito T, Yamamoto D, Matsumura A, Suzuki S, Hisahara S. A Case of Cerebral Tuberculoma Diagnosed by Nested Polymerase Chain Reaction of a Formalin-fixed Paraffin-embedded Brain Biopsy Sample. Intern Med 2022. [PMID: 36328574 DOI: 10.2169/internalmedicine.0356-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 38-year-old man was taken to hospital with generalized clonic seizure. Brain magnetic resonance imaging (MRI) showed multiple ring-enhancing lesions centered in the left frontoparietal lobe. A histopathological examination of a brain biopsy sample revealed granulomatous lesions with caseous necrosis. We extracted DNA from a formalin-fixed paraffin-embedded (FFPE) brain specimen, and nested polymerase chain reaction (PCR) of the DNA sample detected the Mycobacterium tuberculosis-specific insertion sequence IS6110. The lesions worsened after anti-tuberculosis drugs were administered, which we considered to be a paradoxical response and continued treatment. A genetic diagnosis of M. tuberculosis using FFPE specimens is useful for diagnosing tuberculoma.
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Affiliation(s)
- Morihiro Yamamoto
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Tatsuo Manabe
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Kazuki Yokokawa
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | | | - Minoru Yamada
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Rei Miyanaga
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Taro Saito
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Daisuke Yamamoto
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Akihiro Matsumura
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Syuuichirou Suzuki
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
| | - Shin Hisahara
- Department of Neurology, School of Medicine, Sapporo Medical University, Japan
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16
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Gupta S, Sinha U, Raj A. Severe Paradoxical Manifestations in an Immunocompetent Young Female With Tuberculous Meningitis. Cureus 2022; 14:e29953. [PMID: 36348841 PMCID: PMC9635577 DOI: 10.7759/cureus.29953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
A paradoxical reaction, in patients with tuberculous meningitis, is described as either worsening of pre-existing tuberculous lesions or the appearance of new tuberculous lesions after initial improvement with anti-tuberculosis treatment. The condition is often difficult to predict. When severe, it may also result in considerable neurological morbidity and even death. We aim to report such a rare case of severe paradoxical response in a young female with tuberculous meningitis. An 18-year-old female developed severe headache, vomiting, altered sensorium, decreased vision, and paraparesis. She was on anti-tuberculosis treatment (ATT) for tuberculous meningitis for the past two months. Radiological findings revealed tuberculomas in the left cerebral and cerebellar hemispheres, adhesive arachnoiditis in the cervical spine, and moderate communicating hydrocephalus. Visual evoked potential tests provided electrophysiological evidence of optic neuropathy in the left eye. The appearance of new (tuberculoma and adhesive arachnoiditis in the cervical spine), as well as aggravation of pre-existing tuberculous lesions (worsened hydrocephalus and worsened clinical features), were evident in the patient, suggestive of severe paradoxical response (with HIV negative serology). The patient was treated with corticosteroids, and antibiotics, and continued the ATT programme in a conservative manner. Nonetheless, as the patient had severe CNS manifestations, severe disabilities (poor vision, paraparesis, or quadriparesis) and fatalities were inevitable. Notwithstanding, it is crucial to recognize the paradoxical manifestations of tuberculous meningitis to avoid misleading diagnoses and unwarranted management strategies.
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17
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Pastick KA, Kagimu E, Dobbin J, Ssebambulidde K, Gakuru J, Milln J, Nakabuye B, Meya DB, Boulware DR, Cresswell FV, Bahr NC. Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review. Open Forum Infect Dis 2022; 9:ofac513. [PMID: 36267255 PMCID: PMC9578166 DOI: 10.1093/ofid/ofac513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease. Methods We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases. Results We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits. Conclusions The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.
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Affiliation(s)
- Katelyn A Pastick
- Correspondence: Katelyn A. Pastick, MD, Massachusetts General Hospital, Department of Medicine, 55 Fruit St, Boston, MA 02114 ()
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanna Dobbin
- Primary Care and Population Health, University College London, London, United Kingdom
| | | | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jack Milln
- Department of Obstetric Medicine, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Betty Nakabuye
- Department of Obstetrics and Gynecology, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fiona V Cresswell
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
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18
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van Arkel C, Boeree M, Magis-Escurra C, Hoefsloot W, Carpaij N, van Ingen J, Pegge S, Wielders P, Smeenk F, Aarnoutse R, Netea MG, van Crevel R, van Laarhoven A. Interleukin-1 receptor antagonist anakinra as treatment for paradoxical responses in HIV-negative tuberculosis patients: A case series. MED 2022; 3:603-611.e2. [PMID: 36041428 DOI: 10.1016/j.medj.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/19/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Paradoxical inflammatory responses can occur during microbiologically successful antituberculous therapy. Optimal treatment is unknown, but corticosteroids are used most often. It is likely that interleukin-1 (IL-1) plays a central role in the development of these paradoxical responses, and if corticosteroids fail or are undesirable because of adverse effects, anti-IL-1 therapy may therefore be a rational choice. METHODS We present seven HIV-negative tuberculosis patients with paradoxical responses, two with exclusively pulmonary and five with extrapulmonary tuberculosis. All had received corticosteroids, with unsatisfactory effect. Patients were treated with the IL-1 receptor antagonist anakinra and monitored for reduction of fever and inflammatory markers, imaging evidence of stabilization or regression of lesions, and respiratory improvement. FINDINGS Six patients had anemia and four patients had lymphopenia at the start of the antituberculosis treatment. Fever was present in six patients at the moment of paradoxical response. Anakinra resulted in the decrease of fever within days, followed by resolution of symptoms and radiological improvement in five patients. Anakinra induced neutropenia, necessitating its cessation in two patients, who recovered quickly afterward. CONCLUSION Anakinra can be considered in HIV-negative tuberculosis patients with paradoxical responses when steroids fail or are undesired. Given its favorable safety profile and reversible side effects, it is conceivable that anakinra might also be used as first-line adjuvant treatment for paradoxical responses. FUNDING A.v.L. and R.v.C. are supported by National Institutes of Health (R01AI145781).
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Affiliation(s)
- Cynthia van Arkel
- Department of Pulmonary Diseases, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands; Department of Pulmonary Diseases, Catharina Hospital, 5623 EJ Eindhoven, the Netherlands
| | - Martin Boeree
- Department of Pulmonary Diseases, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Cécile Magis-Escurra
- Department of Pulmonary Diseases, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Wouter Hoefsloot
- Department of Pulmonary Diseases, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Neeltje Carpaij
- Department of Pulmonary Diseases, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Jakko van Ingen
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Sjoert Pegge
- Department of Radiology, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Pascal Wielders
- Department of Pulmonary Diseases, Catharina Hospital, 5623 EJ Eindhoven, the Netherlands
| | - Frank Smeenk
- Department of Pulmonary Diseases, Catharina Hospital, 5623 EJ Eindhoven, the Netherlands
| | - Rob Aarnoutse
- Department of Pharmacy, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands
| | - Mihai G Netea
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands; Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Reinout van Crevel
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjan van Laarhoven
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, the Netherlands.
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19
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Qu C, Xu N, Niu D, Wen S, Yang H, Wang S, Wang G. Case Report: Suspected Case of Brucella-Associated Immune Reconstitution Inflammatory Syndrome. Front Immunol 2022; 13:923341. [PMID: 35935931 PMCID: PMC9353035 DOI: 10.3389/fimmu.2022.923341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/24/2022] [Indexed: 11/22/2022] Open
Abstract
Human brucellosis is one of the most prevalent zoonoses. There are many similarities between the pathogenesis of Mycobacterium tuberculosis (MTB) infection and that of brucellosis. Immune reconstitution inflammatory syndrome (IRIS) may occur during the treatment of MTB infection, but it has not been reported in brucellosis cases thus far. We report the case of a 40-year-old male whose condition initially improved after adequate anti-Brucella therapy. However, 3 weeks later, the patient presented with exacerbation of symptoms and development of a paravertebral abscess. After exclusion of other possible causes of clinical deterioration, immune reconstitution inflammatory syndrome (IRIS) with brucellosis was presumed. After supplementation with anti-Brucella treatment with corticosteroids, the abscess disappeared, and the symptoms completely resolved. Our case suggests that it is necessary to be aware of the possible occurrence of IRIS in patients with brucellosis in clinical practice.
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Affiliation(s)
- Chunmei Qu
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Nannan Xu
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dehong Niu
- Department of Oncology, the Fifth People’s Hospital of Jinan, Jinan, China
| | - Sai Wen
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui Yang
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shanshan Wang
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Gang Wang
- Department of Infectious Disease, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Gang Wang,
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20
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Syndrome inflammatoire de reconstitution immune (IRIS) associé à la tuberculose : à propos d’un cas. Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.03.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Ng PY, Kadam M, Batista C. Metastatic cancer masquerading as miliary tuberculosis in an immunocompetent young adult. BMJ Case Rep 2022; 15:15/5/e249880. [PMID: 35609937 PMCID: PMC9131068 DOI: 10.1136/bcr-2022-249880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A healthy, immunocompetent South Asian man in his mid-20s, with a medical history of gastric ulcer, presented to Accident & Emergency with pleuritic chest pain, shortness of breath, fever, night sweats, weight loss, dry cough and asymptomatic iron deficiency anaemia. Following his initial assessment and investigations (chest X-ray, CT and blood tests), a diagnosis of miliary tuberculosis (TB) was made and empirical antimicrobial treatment started. However, subsequent microbiological testing, including urine, blood, induced sputum and lymph node sampling, was negative. Being interpreted as non-diagnostic, the antimicrobial therapy was continued. Following a clinical deterioration while on treatment, the patient’s case was re-evaluated and further investigations, including a repeat CT and a liver biopsy, confirmed a diagnosis of stage IV (T1aN3bM1) gastric carcinoma. Our case highlights the diagnostic challenges in differentiating metastatic cancer from miliary TB. We also focus on possible cognitive biases that may have influenced the initial management decisions.
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Affiliation(s)
- Peng Yun Ng
- Respiratory Medicine, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Mustafa Kadam
- Acute Internal Medicine, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Craig Batista
- Respiratory Medicine, Guy's and St Thomas' Hospitals NHS Trust, London, UK
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22
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Nakamura S, Muramae N, Fujisawa A, Yasuda N, Okano M, Mori K, Otsui K, Sakaguchi K. Hemophagocytic Syndrome-Like Tuberculosis-Immune Reconstitution Inflammatory Syndrome After the Initiation of Hepatic Tuberculosis Treatment. Cureus 2022; 14:e24644. [PMID: 35663666 PMCID: PMC9156395 DOI: 10.7759/cureus.24644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2022] [Indexed: 11/26/2022] Open
Abstract
A 25-year-old Nepalese woman was referred to our hospital because of fever and intermittent abdominal pain with inguinal lymphadenopathy, which had lasted for several months. A liver biopsy of the positron emission tomography-positive lesion led to a diagnosis of hepatic tuberculosis. After the initiation of antituberculosis treatment, her symptoms resolved. However, 11 days after treatment initiation, chest and back pain, high-grade fever, and vomiting appeared and gradually worsened. She developed anemia and her serum ferritin level was elevated. Hemophagocytic syndrome due to the initial deterioration of tuberculosis was suspected and steroid therapy was initiated with the continuation of the antituberculosis drugs. Thereafter, the patient’s condition improved remarkably.
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23
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Alebaji MB, Omara AI. Intestinal Perforation as a Paradoxical Reaction to Tuberculosis. Cureus 2022; 14:e24077. [PMID: 35573566 PMCID: PMC9098107 DOI: 10.7759/cureus.24077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/29/2022] Open
Abstract
Paradoxical reactions (PR) to tuberculosis (TB) treatments are characterized by an initial improvement of the clinical symptoms followed by a clinical or radiological deterioration of existing TB lesions or by the development of new lesions. PR in the gastrointestinal system is a rare phenomenon. Moreover, intestinal perforation is an uncommon but potentially fatal complication of intestinal TB. We report the case of a 29-year-old female who presented with fever and abdominal pain that was associated with watery diarrhea. She was diagnosed as a case of intestinal TB. During her stay, she developed intestinal perforation following the initiation of anti-TB treatment. She was eventually managed as a case of intestinal perforation as a PR to TB.
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24
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Palamit A, Tovichien P, Amornsitthiwat R. Tuberculosis‐immune reconstitution inflammatory syndrome in
HIV
‐negative children. Respirol Case Rep 2022; 10:e0945. [PMID: 35386580 PMCID: PMC8968164 DOI: 10.1002/rcr2.945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/14/2022] [Accepted: 03/14/2022] [Indexed: 11/08/2022] Open
Abstract
Even though tuberculosis‐immune reconstitution inflammatory syndrome (TB‐IRIS) is usually found in HIV‐positive patients receiving antiviral treatment, it can also occur in HIV‐negative patients especially if they have risk factors. We report a unique case of TB‐IRIS in an immunocompetent child presenting with new onset of pleuritic chest pain after receiving anti‐TB drugs. TB‐IRIS should be considered as a differential diagnosis in case of clinical deterioration or appearance of new typical lesions despite appropriate anti‐TB treatment for more than 2 weeks in the absence of persistently active TB or any other alternative causes. This will prevent physicians from misdiagnosis as superimposed infections, treatment failure or TB relapse.
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Affiliation(s)
- Apinya Palamit
- Division of Pulmonology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | - Prakarn Tovichien
- Division of Pulmonology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | - Ramida Amornsitthiwat
- Department of Radiology, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
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25
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Notghi AAA, Hosseini F, Tsogas N. Severe diffuse proliferative bronchiolitis complicating culture-proven disseminated BCG infection after intravesical instillation for bladder cancer. BMJ Case Rep 2022; 15:e248681. [PMID: 35321917 PMCID: PMC8943779 DOI: 10.1136/bcr-2021-248681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 70s was admitted to hospital following several months of dyspnoea, night sweats, weight loss and, latterly, fevers. His symptoms correlated with a second maintenance cycle of intravesical BCG instillation for superficial bladder cancer. Blood tests showed raised C-reactive protein, alkaline phosphatase and gamma-GT, although extensive further investigations did not reveal any specific cause. Treatment for a presumed diagnosis of disseminated BCG infection was started, following which his fevers ceased. Later available results of liver biopsy taken prior to treatment supported this diagnosis, and mycobacterial blood and urine cultures grew Mycobacterium bovis Recovery was complicated by a severe diffuse proliferative bronchiolitis which responded to corticosteroids. This case highlights an important dichotomy in the pathophysiology of disseminated BCG infection. It demonstrates how morbidity can be caused by both a direct dissemination of the organism and an immune hypersensitivity response in the same patient.
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26
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Khan FG, Fan S. A case of paradoxical reaction after treatment of generalized tuberculous lymphadenopathy in a peritoneal dialysis patient. SAGE Open Med Case Rep 2022; 10:2050313X221084839. [PMID: 35308055 PMCID: PMC8928346 DOI: 10.1177/2050313x221084839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/10/2022] [Indexed: 02/03/2023] Open
Abstract
Paradoxical reaction (also known as Jarisch–Herxheimer reaction) is a self-limited response to endotoxin released from dead bacteria after starting treatment and is characterized by constitutional symptoms such as fever, headache, dizziness and exacerbation of cutaneous lesions. We report a rare case of a 55-year-old gentleman, on peritoneal dialysis, who developed fever, dizziness and cloudy dialysate after starting anti-tuberculous treatment for disseminated tuberculous lymphadenitis. He was started on antibiotics for suspected peritoneal dialysis peritonitis and anti-tuberculosis treatment was continued. However, all his cultures turned out negative including peritoneal 16S ribosomal RNA. The diagnosis of paradoxical worsening following anti-tuberculosis treatment was made. His peritoneal dialysis was continued and he made full recovery after 8 months of therapy. This case highlights the fact that in a peritoneal dialysis patient, paradoxical reaction can present as cloudy dialysate with raised infective markers.
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Affiliation(s)
| | - Stanley Fan
- The Royal London Hospital, Barts Health NHS Trust, London, UK
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27
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Sathirapanya P, Amornpojnimman T, Srisilpa S. Neurological paradox during treatment in a non-HIV patient with pulmonary tuberculosis: A case report. ASIAN PAC J TROP MED 2022. [DOI: 10.4103/1995-7645.356995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chen YL, Kuo YW, Wu HD, Wang JY, Wang HC. The application of ultrasound shear wave elastography in the prediction of paradoxical upgrading reaction in tuberculous lymphadenitis. a pilot study. J Formos Med Assoc 2021; 121:1696-1704. [PMID: 34953644 DOI: 10.1016/j.jfma.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Paradoxical upgrading reaction (PUR) indicates the unanticipated deterioration during therapy in patients with tuberculous lymphadenitis. We investigated the diagnostic performance of the ultrasonography and shear wave elastography (SWE) in predicting the therapeutic response of peripheral tuberculous lymphadenitis. METHODS A prospective observational study was conducted from December 2017 to August 2020. Participants diagnosed with peripheral tuberculous lymphadenitis were included for a longitudinal follow-up utilizing ultrasonography with two-dimensional SWE to record sonographic features and the maximum elasticity value (Emax). We defined PUR as the development of any worsening symptoms of the pre-existing lymphadenitis within one month after the previous ultrasonography. RESULTS A total of 108 sonographic and SWE examinations were performed in 20 enrollees (75% woman), and their mean ( ± standard deviation) age was 49.6 ( ± 22.7) years. The area under the receiver operating characteristic curve of Emax to predict the next-month PUR was 0.906 at the cut-point of 85 kPa, with an accuracy of 87.0%, a sensitivity of 81.1% and a specificity of 87.9%. Multivariate analysis indicated that Emax > 85 kPa (OR: 24.85, 95% CI: 4.01-154.08, p < 0.001), Emax increment rate >2 kPa/month (OR: 15.14, 95% CI: 4.24-54.06, p < 0.001), and heterogeneous echogenicity (OR: 4.37, 95% CI: 1.16-16.43, p = 0.029) were independent sonographic predictors for PUR in the coming month. CONCLUSIONS A high and non-declining Emax level and heterogeneous echogenicity were associated with the next-month PUR of tuberculous lymphadenitis. Ultrasonography with SWE may be a potential radiologic marker to predict the therapeutic response of tuberculous lymphadenitis.
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Affiliation(s)
- Yen-Lin Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yao-Wen Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Yuan Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Chien Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan.
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29
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Pal L, Nandani R, Kumar P, Swami B, Roy G, Bhaskar S. Macrophages Are the Key Players in Promoting Hyper-Inflammatory Response in a Mouse Model of TB-IRIS. Front Immunol 2021; 12:775177. [PMID: 34899731 PMCID: PMC8662811 DOI: 10.3389/fimmu.2021.775177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/29/2021] [Indexed: 01/01/2023] Open
Abstract
TB-IRIS is an abnormal inflammatory response in a subset of HIV-TB co-infected patients shortly after initiation of anti-retroviral therapy (ART). Therapy in these patients could have greatly improved the life expectancy as ART reconstitutes the function and number of CD4+ T cells and many patients see improvement in symptoms but paradoxically up to 54% of co-infected patients develop TB-IRIS. Different studies have indicated that both innate and adaptive immunity are involved in the pathology of IRIS but the role of macrophages in abnormal activation of CD4+ T cells is poorly understood. Since macrophages are one of the major antigen-presenting cells and are infected by M.tb at a high frequency, they are very much likely to be involved in the development of TB-IRIS. In this study, we have developed a mouse model of experimental IRIS, in which M.tb-infected T-cell knockout mice undergo a fatal inflammatory disease after CD4+ T cell reconstitution. Lung macrophages and blood monocytes from M.tb-infected TCRβ-/- mice showed upregulated expression of cell surface activation markers and also showed higher mRNA expression of inflammation-associated chemokines and matrix metalloproteases responsible for tissue damage. Furthermore, cytokine and TLR signaling feedback mechanism to control excessive inflammation was also found to be dysregulated in these macrophages under lymphopenic conditions. Previous studies have shown that hyperactive CD4+ T cells are responsible for disease induction and our study shows that somehow macrophages are in a higher activated state when infected with M.tb in an immune-deficient condition, which results in excessive activation of the adoptively transferred CD4+ T cells. Understanding of the mechanisms underlying the pathophysiology of TB-IRIS would facilitate identification of prospective biomarkers for disease development in HIV-TB co-infected patients before starting antiretroviral therapy.
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Affiliation(s)
| | | | | | | | | | - Sangeeta Bhaskar
- Product Development Cell-1, National Institute of Immunology, New Delhi, India
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30
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Shinohara T, Morizumi S, Sumitomo K. Varying clinical presentations of nontuberculous mycobacterial disease : Similar to but different from tuberculosis. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 68:220-227. [PMID: 34759134 DOI: 10.2152/jmi.68.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The incidence rate of pulmonary nontuberculous mycobacterial disease (PNTMD) in Japan is the highest among major industrialized nations. Although the typical clinical course and radiological manifestations of PNTMD are different from those of pulmonary tuberculosis (TB), confusion about these mycobacterial diseases leads to a diagnostic pitfall. Diagnostic challenges include the coexistence of Mycobacterium tuberculosis (MTB) and nontuberculous mycobacteria (NTM), false positives for NTM in MTB nucleic acid amplification tests, microbial substitution, and abnormal radiological manifestations caused by NTM. Features of extrapulmonary NTM diseases, such as pleurisy, vertebral osteomyelitis, and disseminated disease, are different from the corresponding tuberculous diseases. Moreover, the immunological background of the patient (status of human immunodeficiency virus infection with or without antiviral therapy, continuation or discontinuation of immunosuppressive therapy, use of immune checkpoint inhibitor, pregnancy and delivery, etc.) influences the pathophysiology of mycobacterial diseases. This review describes the varying clinical presentations of NTM disease with emphasis on the differences from TB. J. Med. Invest. 68 : 220-227, August, 2021.
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Affiliation(s)
- Tsutomu Shinohara
- Department of Community Medicine for Respirology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Division of Internal Medicine, Japan Agricultural Cooperatives Kochi Hospital, Kochi, Japan.,Department of Clinical Investigation, National Hospital Organization Kochi Hospital, Kochi, Japan
| | - Shun Morizumi
- Department of Community Medicine for Respirology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan.,Division of Internal Medicine, Japan Agricultural Cooperatives Kochi Hospital, Kochi, Japan
| | - Kenya Sumitomo
- Division of Internal Medicine, Japan Agricultural Cooperatives Kochi Hospital, Kochi, Japan
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31
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Awasty SS, Jafri S, Manzoor S, Yaqub A. Hypercalcemia Secondary to Immune Reconstitution Inflammatory Syndrome in an HIV-Infected Individual With Mycobacterium avium Complex. Cureus 2021; 13:e18174. [PMID: 34703699 PMCID: PMC8530549 DOI: 10.7759/cureus.18174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/05/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an uncommon cause of hypercalcemia in HIV-infected patients recently started on highly active antiretroviral therapy (HAART). It is hypothesized that increased granulomatous formation due to IRIS leads to an overproduction of calcitriol. High levels of calcitriol, then, can lead to significant hypercalcemia. We present the case of a 63-year-old male with HIV off HAART presented to the emergency room for confusion, frequent falls, and cough. His CD-4 count was noted to be below 35 cells/µL (255-2,496). Over the course of the hospitalization, the patient was found to have disseminated Mycobacterium avium complex (MAC) infection and was initiated on HAART. Initiation of HAART was followed by an increase in calcium up to 14.1 mg/dL. The hypercalcemia did not respond to either Calcitonin or Pamidronate. Consideration was then given to IRIS in the setting of MAC infection leading to increased granulomatous formation. Calcium levels normalized within three days of therapy after initiation of prednisone for the treatment of IRIS. It is thought that an increase in CD-4 counts leads to the recovery of an immune response. This can lead to granulomatous inflammation. An increase in granuloma formation can cause hypercalcemia due to overproduction of calcitriol via increased 1𝛼-hydroxylase activity from macrophages. Our case report describes IRIS-mediated hypercalcemia in an HIV-infected individual with MAC infection. This unusual cause of severe hypercalcemia should be considered in differential diagnoses for immunocompromised patients in the appropriate setting. Prompt treatment of IRIS with glucocorticoids can lead to the resolution of hypercalcemia.
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Affiliation(s)
- Sanjana S Awasty
- Division of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, USA
| | - Sabih Jafri
- Division of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, USA
| | - Saima Manzoor
- Division of Endocrinology, Diabetes and Metabolism, University of Cincinnati Medical Center, Cincinnati, USA
| | - Abid Yaqub
- Division of Endocrinology, Diabetes and Metabolism, University of Cincinnati, College of Medicine, Cincinnati, USA
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32
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Paradoxical manifestations during tuberculous meningitis treatment among HIV-negative patients: a retrospective descriptive study and literature review. Neurol Sci 2021; 43:2699-2708. [PMID: 34705128 DOI: 10.1007/s10072-021-05693-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most frequent, severe, and disabling form of central nervous system (CNS) tuberculosis (TB). TBM paradoxical manifestations are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids. METHODS Retrospective descriptive study of consecutive HIV-negative adult patients (≥ 18 years) with definitive TBM who developed a paradoxical manifestation following anti-TB in a tertiary-care hospital in Mexico from 2009 to 2019; we also conducted a literature review of published cases/series of paradoxical manifestations in HIV-negative patients from 1980 to 2020. RESULTS We detected 84 cases of definitive TBM; 55 (68.7%) HIV-negative patients and 29 (36.3%) HIV-infected patients. Among HIV-negative patients, four (7.3%), three female and one male (19-49 years old), developed a paradoxical manifestation within 4-14 weeks following treatment initiation despite receiving adequate corticosteroid doses; Mycobacterium bovis was isolated from the cerebrospinal fluid of three cases and Mycobacterium tuberculosis in one more. Two patients developed vasculopathy-related cerebral infarctions, one severe basilar meningitis, and hydrocephalus, one more a tuberculoma. Two were treated with intravenous cyclophosphamide, and two with steroids. One of the patients treated with steroids died; patients who received cyclophosphamide had a good clinical response. CONCLUSIONS This case series illustrates the diverse clinical/radiologic paradoxical manifestations of TBM in HIV-negative patients. Cyclophosphamide may be safe and effective in treating TBM-associated paradoxical manifestations. Specific diagnostic and care protocols for these patients are needed.
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33
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Elusive tuberculous meningitis with rare neurological complication of longitudinally extensive transverse myelitis: a case report. Spinal Cord Ser Cases 2021; 7:82. [PMID: 34521808 PMCID: PMC8438549 DOI: 10.1038/s41394-021-00445-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Longitudinally extensive transverse myelitis (LETM) is inflammation of the spinal cord that spans three or more spinal segments. LETM is a rare occurrence on its own and has seldom been reported with tuberculous meningitis (TBM), the rarest and deadliest of tuberculous manifestations. TBM is usually seen in children, the immunocompromised, or those with a previous history of tuberculosis infection. CASE PRESENTATION A 24-year-old healthy male with no co-morbidities or history of tuberculosis presented with fever and headache for the past 3 months. The patient's Kernig's and Brudzinski's signs were both negative, with bilateral abnormal plantar reflexes. The neurological level of injury was T8 and the patient was classified as AIS grade A. His CSF analysis showed a lymphocytic picture. However, both GeneXpert and Ziehl-Neelsen staining came back negative for Mycobacterium tuberculosis. MRI scans of the brain and thoracic spine revealed enhancing nodules and ring lesions in the brain and spinal cord, along with the rare complication of LETM, extending from T2 to T9. DISCUSSION Although Mycobacterium tuberculosis was never isolated, the patient started recovering as soon as antituberculous therapy was initiated. Hence, more emphasis needs to be placed on radiological imaging in the management of rare medical emergencies like tuberculous meningitis, especially in areas where tuberculosis is rampant and endemic, rather than waiting for a positive culture. This case report also demonstrates the growing evidence that transverse myelitis and/or LETM is associated with TBM.
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34
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Owens DR, Medalla CM, Brown KN, Wijewardena K, Thomas CP, Iro MA, Jones CE, Faust SN, Patel SV. Problem-solving in clinical practice: Persisting respiratory distress in a premature infant. Arch Dis Child Educ Pract Ed 2021; 106:239-243. [PMID: 33077533 DOI: 10.1136/archdischild-2019-317757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 07/12/2020] [Accepted: 08/28/2020] [Indexed: 11/03/2022]
Abstract
The deterioration of a previously stable preterm infant is a common scenario on the neonatal unit. The the most common bacterial causes of deterioration are nosocomial infections, such as coagulase-negative Staphylococcus and Staphylococcus aureus Non-infective conditions such as pulmonary haemorrhage, anaemia of prematurity and necrotising enterocolitis may also cause preterm infants to deteriorate. This case chronicles the unusual diagnostic journey of an infant born at 27+1 weeks who deteriorated at 26 days of life and did not respond to antimicrobial therapy as anticipated.
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Affiliation(s)
- Daniel R Owens
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | | | - Kelly N Brown
- Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kishani Wijewardena
- Department of Child Health, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Claire P Thomas
- Department of Clinical Microbiology/Infection, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Mildred A Iro
- Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK.,Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christine E Jones
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Sanjay Valabh Patel
- Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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35
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Muhammed H, Jain A, Pattanaik SS, Chatterjee R, Naveen R, Kabeer H, Gupta L, Misra DP, Agarwal V, Lawrence A, Misra R, Aggarwal A. Clinical spectrum of active tuberculosis in patients with systemic lupus erythematosus. Rheumatol Int 2021; 41:2185-2193. [PMID: 34191047 DOI: 10.1007/s00296-021-04933-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION There is paucity of data on tuberculosis in Indian patients with systemic lupus erythematosus (SLE). We retrospectively studied clinical features and outcome of tuberculosis in SLE. METHODS Medical records of patients who developed tuberculosis simultaneous or after the diagnosis of SLE were retrospectively reviewed. All patients fulfilled 1997 ACR and/or SLICC 2012 classification criteria for SLE. A diagnosis of tuberculosis required bacteriological, histopathological or CT/MRI suggestive of tuberculosis and initiation of four drug antituberculous therapy. Baseline parameters were compared with the rest of cohort to identify predictors of tuberculosis. RESULTS In our cohort of 1335 SLE patients, 48 (3.6%) developed tuberculosis. Incidence of tuberculosis was calculated to be 733 per 100,000 patient years and occurred after a mean disease duration of 3.0 ± 4.1 years. Extrapulmonary tuberculosis (n = 37) was commoner than pulmonary tuberculosis (n =11). Most common radiological pattern in pulmonary tuberculosis was miliary and musculoskeletal TB was most common extrapulmonary TB. A microbiological diagnosis was obtained in 52.1% patients. Male gender was associated with higher risk of tuberculosis [OR 3.30 (1.55-7.05)]. Mortality was 14.5% and all patients who died had either disseminated (n = 5) or central nervous system (CNS) tuberculosis (n = 2). CONCLUSION Incidence of tuberculosis in SLE is higher than general population and is associated with different phenotype and higher mortality. Male gender was associated with increased risk of tuberculosis in SLE.
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Affiliation(s)
- Hafis Muhammed
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.,Department of General Medicine, Government Medical College, Calicut, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.,Division of Clinical Immunology and Rheumatology, SMS Medical College and Hospital, Jaipur, India
| | - Sarit Sekhar Pattanaik
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rudrarpan Chatterjee
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - R Naveen
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Hina Kabeer
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Durga P Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Able Lawrence
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ramnath Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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36
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OBrien S, Griffin B, McLaughlin AM, Keane J. ANCA associated glomerulonephritis in tuberculosis: a paradoxical reaction. BMJ Case Rep 2021; 14:14/6/e241904. [PMID: 34130975 DOI: 10.1136/bcr-2021-241904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of antineutrophil cytoplasmic antibodies (ANCA)-associated rapidly progressive glomerulonephritis in the context of treatment of pulmonary tuberculosis (TB). A 42-year-old woman was treated for drug-susceptible pulmonary TB and represented with paradoxical worsening of symptoms and radiological features. She was HIV negative. A severe acute kidney injury with features of glomerulonephritis was evident on admission. Perinuclear ANCA and antimyeloperoxidase antibodies were present in serum and renal biopsy was consistent with ANCA-associated vasculitis. The patient was successfully treated with both antituberculous therapy and immunosuppression (corticosteroids and mycophenolate mofetil) with subsequent clinical improvement and amelioration of renal function. We propose this is the first case that describes the association between paradoxical reactions during TB treatment and ANCA-associated glomerulonephritis.
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Affiliation(s)
- Shane OBrien
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
| | - Brenda Griffin
- Department of Renal Medicine, St James's Hospital, Dublin, Ireland
| | | | - Joseph Keane
- Department of Respiratory Medicine, St James's Hospital, Dublin, Ireland
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37
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Kechaou I, Abida R, Hamdi MS, Hassine LB. Palate Tuberculosis with Paradoxical Lymphadenitis. J Glob Infect Dis 2021; 13:94-96. [PMID: 34194177 PMCID: PMC8213087 DOI: 10.4103/jgid.jgid_266_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/05/2020] [Accepted: 12/22/2020] [Indexed: 11/04/2022] Open
Abstract
Oral cavity involvement in tuberculosis (TB), particularly palatine, is extremely rare and mostly described in case reports. Management of these cases usually responds to classic antitubercular therapy. Some serious complications such as paradoxical reactions (PRs) may however occur, making it more challenging for physicians to treat and to manage. We present a case of a 30-year-old female patient with a history of juvenile idiopathic arthritis and systemic lupus erythematosus who presented a bifocal form of TB involving the palate and the cervical lymph nodes. Follow-up after 2 months of proper antitubercular treatment revealed a PR of the lymph nodes contrasting with a favorable outcome of the oral lesions. It seems useful to raise all clinicians' awareness to suspect TB when they deal with chronic drug-resistant oral erosions and to keep in mind the diagnosis of PR when there is a worsening of one lesion and a favorable outcome of another.
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Affiliation(s)
- Ines Kechaou
- Department B of Internal Medicine, Faculty of Medicine, Charles Nicolle Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Rym Abida
- Department B of Internal Medicine, Faculty of Medicine, Charles Nicolle Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Salah Hamdi
- Department B of Internal Medicine, Faculty of Medicine, Charles Nicolle Hospital, University of Tunis El Manar, Tunis, Tunisia
| | - Lamia Ben Hassine
- Department B of Internal Medicine, Faculty of Medicine, Charles Nicolle Hospital, University of Tunis El Manar, Tunis, Tunisia
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38
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Flynn AG, Aiona K, Haas MK, Reves R, Belknap R. Clinical Characteristics of Active Tuberculosis Diagnosed After Starting Treatment for Latent Tuberculosis Infection. Clin Infect Dis 2021; 71:1320-1323. [PMID: 31773132 DOI: 10.1093/cid/ciz1157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/26/2019] [Indexed: 11/14/2022] Open
Abstract
Although rare, subclinical tuberculosis disease can be missed during evaluations for latent tuberculosis infection, and can manifest with symptoms during latent tuberculosis treatment. Among over 8000 patients treated for latent tuberculosis we found no evidence of acquired drug resistance, underscoring the safety of rifampin monotherapy for latent tuberculosis.
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Affiliation(s)
- Andrew G Flynn
- Department of Family Medicine, Duke University Medical Center, Durham, North Carolina, USA.,University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kaylynn Aiona
- Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Michelle K Haas
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Randall Reves
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Robert Belknap
- University of Colorado School of Medicine, Aurora, Colorado, USA.,Denver Health and Hospital Authority, Denver, Colorado, USA
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39
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Abstract
Tuberculosis is an established cause of pyrexia of unknown origin and can implicate practically any human organ system. Splenic involvement is common in disseminated or miliary tuberculosis following hematogenous spread, but isolated splenic involvement is a very rare phenomenon. We report the case of a 30-year-old immunocompetent female who presented with high-grade fever and dull aching pain in the left hypochondrium for three months. Laboratory data provided no diagnostic information. Abdominal ultrasonography revealed an enlarged spleen with multiple small hypoechoic lesions that were corroborated on computed tomography. No pulmonary involvement or primary focus of infection was discernible elsewhere. Splenic fine needle aspiration cytology helped clinch a histopathological diagnosis of isolated splenic tuberculosis. Administration of anti-tubercular therapy resulted in resolution of the disease and an excellent outcome in our patient.
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Affiliation(s)
- Sahil Grover
- Internal Medicine, Government Medical College & Hospital, Chandigarh, IND
| | - Yajur Arya
- Internal Medicine, Government Medical College & Hospital, Chandigarh, IND
| | - Saurabh Gaba
- Internal Medicine, Government Medical College & Hospital, Chandigarh, IND
| | - Monica Gupta
- Internal Medicine, Government Medical College & Hospital, Chandigarh, IND
| | - Arshi Syal
- Internal Medicine, Government Medical College & Hospital, Chandigarh, IND
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40
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Lu Y, Hu Z, Wang F, Yao H, Zhu H, Wang Z, Song Z, Chen R, Liu D. Worsening CSF parameters after the start of anti-tuberculosis treatment predicts intracerebral tuberculoma development. Int J Infect Dis 2020; 101:395-402. [DOI: 10.1016/j.ijid.2020.09.1457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 02/02/2023] Open
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41
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Dian S, Hermawan R, van Laarhoven A, Immaculata S, Achmad TH, Ruslami R, Anwary F, Soetikno RD, Ganiem AR, van Crevel R. Brain MRI findings in relation to clinical characteristics and outcome of tuberculous meningitis. PLoS One 2020; 15:e0241974. [PMID: 33186351 PMCID: PMC7665695 DOI: 10.1371/journal.pone.0241974] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 10/23/2020] [Indexed: 11/18/2022] Open
Abstract
Neuroradiological abnormalities in tuberculous meningitis (TBM) are common, but the exact relationship with clinical and inflammatory markers has not been well established. We performed magnetic resonance imaging (MRI) at baseline and after two months treatment to characterise neuroradiological patterns in a prospective cohort of adult TBM patients in Indonesia. We included 48 TBM patients (median age 30, 52% female, 8% HIV-infected), most of whom had grade II (90%), bacteriologically confirmed (71%) disease, without antituberculotic resistance. Most patients had more than one brain lesion (83%); baseline MRIs showed meningeal enhancement (89%), tuberculomas (77%), brain infarction (60%) and hydrocephalus (56%). We also performed an exploratory analysis associating MRI findings to clinical parameters, response to treatment, paradoxical reactions and survival. The presence of multiple brain lesion was associated with a lower Glasgow Coma Scale and more pronounced motor, lung, and CSF abnormalities (p-value <0.05). After two months, 33/37 patients (89%) showed worsening of MRI findings, mostly consisting of new or enlarged tuberculomas. Baseline and follow-up MRI findings and paradoxical responses showed no association with six-month mortality. Severe TBM is characterized by extensive MRI abnormalities at baseline, and frequent radiological worsening during treatment.
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Affiliation(s)
- Sofiati Dian
- Department of Neurology, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
- * E-mail: ,
| | - Robby Hermawan
- Department of Radiology, St. Borromeus Hospital, Bandung, Indonesia
| | - Arjan van Laarhoven
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sofia Immaculata
- Infectious Disease Research Center, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Tri Hanggono Achmad
- Infectious Disease Research Center, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Infectious Disease Research Center, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Farhan Anwary
- Department of Radiology, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Ristaniah D. Soetikno
- Department of Radiology, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Ahmad Rizal Ganiem
- Department of Neurology, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Hasan Sadikin Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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42
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Mobeireek A, Al Shekail NA. Relapsing paradoxical reaction in miliary tuberculosis: a case report and literature review. Respirol Case Rep 2020; 8:e00658. [PMID: 32995009 PMCID: PMC7507520 DOI: 10.1002/rcr2.658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/08/2022] Open
Abstract
Paradoxical reaction (PR) after initiating anti-tuberculous therapy (ATT) is a well-recognized immune phenomenon. Less recognized, however, is a pulmonary reaction that is associated with miliary tuberculosis (TB), which can be a source of diagnostic confusion and progress to respiratory failure and acute respiratory distress syndrome (ARDS). We report an elderly patient who developed PR associated with respiratory failure following ATT for miliary TB, with radiological and pathological documentation. He responded to corticosteroids, but relapsed twice when the dose was reduced. It is imperative to be familiar with this form of PR to avoid diagnostic pitfalls and initiate appropriate therapy.
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Affiliation(s)
- Abdullah Mobeireek
- Section of Pulmonary Medicine, Department of Medicine King Faisal Specialist Hospital and Research Centre Riyadh Saudi Arabia
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Lee JH, Kim OH, Kim YJ, Shim TS, Jo KW. Changes in chest X-ray findings in 1- and 2-month group after treatment initiation for suspected pulmonary tuberculosis. Korean J Intern Med 2020; 35:1145-1153. [PMID: 32066222 PMCID: PMC7487304 DOI: 10.3904/kjim.2019.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/12/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND/AIMS Although re-evaluation of radiographic follow-up after 2 to 3 months of therapy is recommended for patients administered anti-tuberculosis medication owing to suspected pulmonary tuberculosis, reported findings are limited. Therefore, this study aimed to investigate changes in 1- and 2-month chest X-ray (CXR) findings after the treatment initiation and compared them according to the final diagnosis of tuberculosis or non-tuberculosis. METHODS Patients who started anti-tuberculosis medication for suspected pulmonary tuberculosis were selected at a tertiary referral hospital in South Korea between January 2012 and December 2015. Changes in the 1- and 2-month CXR findings were classified as improved, unchanged, and aggravated. RESULTS Among the 120 patients enrolled in the 1-month CXR group, 76 (63.3%) had the final diagnosis of tuberculosis. Comparison between the 1-month CXR changes and diagnosis showed that the final diagnosis was tuberculosis in 81.8% (45/55), 50.0% (26/52), and 38.5% (5/13) of patients whose 1-month CXR was improved, unchanged, and aggravated, respectively. In the 2-month CXR group, 167 patients were enrolled, and 139 (83.2%) of them were diagnosed with tuberculosis. Tuberculosis was the final diagnosis in 92.6% (100/108), 70.0% (35/50), and 44.4% (4/9) patients with improved, unchanged, and aggravated 2-month CXR findings, respectively. In patients with the final diagnosis of non-tuberculosis, nontuberculous mycobacteria and malignancy were the most common causes of improved and aggravated 1- and 2-month CXR findings, respectively. CONCLUSION Two-month CXR findings were of limited value for deciding on whether to continue anti-tuberculosis treatment. One-month CXR findings could help determine the need for further work-up.
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Affiliation(s)
- Jang Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ock-Hwa Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Joo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Wook Jo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Kyung-Wook Jo, M.D. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-5783 Fax: +82-2-3010-6968 E-mail:
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44
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Chandra PS. The Unbearable Suffering Followed by Ineffable Relief of a Good Doctor: Tuberculosis as a Malady, Still Rules the Roost. Neurol India 2020; 67:1405-1407. [PMID: 31857524 DOI: 10.4103/0028-3886.273619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- P Sarat Chandra
- Head of Unit I, Department of Neurosurgery, AIIMS, New Delhi, India
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Arora A, Katoch D, Jain S, Singh SR, Gupta V. Yellow Subretinal Lesions following Initiation of Antituberculosis Therapy in A Tubercular Choroidal Granuloma: A Sign of Paradoxical Worsening? Ocul Immunol Inflamm 2020; 30:29-33. [PMID: 32783681 DOI: 10.1080/09273948.2020.1780272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe the presentation and management of atypical subretinal lesions following initiation of antitubercular therapy for a tubercular choroidal granuloma. CASE REPORT An 18-year-old female was diagnosed with choroidal granuloma and shallow exudative retinal detachment in the left eye. Biopsy from a cervical lymph node was positive for tuberculosis. She was treated with antitubercular therapy (ATT) and oral steroids. After one week of therapy exudative detachment increased markedly and discrete yellowish-white subretinal lesions appeared first in the inferior periphery, then temporally and later involved the macula leading to a drop in visual acuity. A diagnosis of paradoxical worsening was considered and she was managed with a higher dose of oral corticosteroids, intravitreal methotrexate and intravitreal ranibizumab. The granuloma healed and the subretinal lesions as well as exudative detachment gradually resolved with improvement in visual acuity. CONCLUSION Subretinal yellow-white lesions may develop as a paradoxical response to ATT.
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Affiliation(s)
- Atul Arora
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deeksha Katoch
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahil Jain
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Simar Rajan Singh
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishali Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Takahashi S, Otomo K, Kawakami Y, Nakamura M. Uveitis developing in tuberculous lymphadenitis-associated Behçet's disease during anti-tuberculosis therapy. Respirol Case Rep 2020; 8:e00617. [PMID: 32670586 PMCID: PMC7350283 DOI: 10.1002/rcr2.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/12/2020] [Accepted: 06/21/2020] [Indexed: 11/19/2022] Open
Abstract
Behçet's disease (BD) is thought to be elicited by triggers such as tuberculosis (TB) infection in individuals with genetically aberrant immune activity, although the exact pathogenesis remains unknown. Seven cases of BD thought to be triggered by TB have been reported to date. In all cases, Behçet's symptoms improved smoothly after starting TB treatment. We present the first report of uveitis developing two months after starting TB treatment in a 46-year-old woman with tuberculous lymphadenitis presenting with oral and genital ulcers and erythema nodosum-like lesions on diagnosis of TB. The appearance of uveitis was attributed to a paradoxical reaction in TB because of simultaneous relapse of lymphadenopathy and retinal findings on fluorescein angiography. Although rare, physicians should be aware that ocular involvement can occur during anti-TB therapy, most likely with extrapulmonary TB, because ocular involvement may decrease patient quality of life if visual symptoms become irreversible with delayed diagnosis and treatment.
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Affiliation(s)
- Saeko Takahashi
- Department of Pulmonary MedicineTokyo Saiseikai Central HospitalTokyoJapan
| | - Kotaro Otomo
- Division of Rheumatology, Department of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Yoko Kawakami
- Department of OphthalmologyTokyo Saiseikai Central HospitalTokyoJapan
| | - Morio Nakamura
- Department of Pulmonary MedicineTokyo Saiseikai Central HospitalTokyoJapan
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Kang SH, Moon HS, Park JH, Kim JS, Kang SH, Lee ES, Kim SH, Lee BS, Sung JK, Jeong HY, Lee KH. Intestinal Perforation as a Paradoxical Reaction to Antitubercular Therapy: A Case Report. Ann Coloproctol 2020; 37:S18-S23. [PMID: 32674552 PMCID: PMC8359699 DOI: 10.3393/ac.2020.03.16.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/16/2020] [Indexed: 11/10/2022] Open
Abstract
Paradoxical reactions to tuberculosis (TB) treatment are characterized by an initial improvement of the clinical symptoms followed by clinical or radiological deterioration of existing tuberculous lesions, or by development of new lesions. Intestinal perforation in gastrointestinal TB can occur as a paradoxical reaction to antitubercular therapy. A 55-year-old man visited the outpatient department with lower abdominal pain and weight loss. He was diagnosed with intestinal TB and started antitubercular therapy. After 3 months of antitubercular therapy, a colonoscopy revealed improvement of the disease. Three days after the colonoscopy, the patient visited the emergency room complaining of abdominal pain. Abdominal computed tomography revealed extraluminal air-filled spaces in the pelvic cavity. We diagnosed a small bowel perforation and performed an emergency laparotomy and a right hemicolectomy with small bowel resection. This report describes the case of intestinal perforation presenting as a paradoxical reaction to antitubercular and provides a brief literature review.
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Affiliation(s)
- Sung Hoon Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ju Seok Kim
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Eaum Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seok Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byung Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Kyung Ha Lee
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
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Volpe-Chaves CE, Lacerda MLGG, Castilho SB, Fonseca SSO, Saad BAA, Franciscato C, Tibana TK, Nunes TF, Venturini J, de Oliveira SMDVL, Paniago AMM. Vertebral tuberculosis as a paradoxical reaction to the treatment of pulmonary and meningeal tuberculosis in an immunocompetent patient: A case report. Medicine (Baltimore) 2020; 99:e20012. [PMID: 32481268 PMCID: PMC7249907 DOI: 10.1097/md.0000000000020012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/05/2020] [Accepted: 03/26/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Paradoxical reaction in tuberculosis (TB) is defined as the reappearance of general symptoms, aggravation of pre-existing diseases, or appearance of new lesions despite adequate anti-TB therapy. It may result from the hyperactivity of the immune response, resulting in an intense inflammation. There are few cases of vertebral TB reported as paradoxical reaction, mainly among immunocompetents patients. PATIENT CONCERNS We describe a male immunocompetent patient with confirmed pulmonary and meningeal TB. He was readmitted after 60 days of adequate treatment, with vertebral TB and paravertebral abscess, despite clinical improvement of the other locations. We defined as an uncommon case of a paradoxical reaction, confirmed by nuclear magnetic resonance and molecular rapid test for TB. DIAGNOSIS Mycobacterium tuberculosis (MTB) was detected in cerebrospinal fluid by molecular rapid test (Gene Xpert MTB/ rifampicina method). Sputum research and culture were positive for the same agent. Lumbosacral spine nuclear magnetic resonance revealed bone destruction from T8 to T11, and a paravertebral collection was found. Gene Xpert MTB/rifampicina and culture were positive for M tuberculosis in the drained material of the paravertebral abscess. INTERVENTIONS The paravertebral abscess was drainage by tomography-guided. Treatment with 4 anti-TB drugs was extended for 60 days and 2 anti-TB drugs was maintained for 10 months. There was a complete clinical improvement. OUTCOME After draining the paravertebral abscess, the patient progressively improved and was discharged for outpatient follow-up. He was on antituberculous drugs for 1 year; subsequently, complete resolution of the infection was reported. CONCLUSION Paradoxical reaction may be a difficult diagnosis in immunocompetent patient. Vertebral TB as a paradoxical reaction is an uncommon presentation. Therapeutic failure or resistance to treatment should be ruled out to confirm the diagnosis of paradoxical reaction.
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Affiliation(s)
- Cláudia Elizabeth Volpe-Chaves
- Graduate Program in Infectious and Parasitic Diseases of Federal University of Mato Grosso do Sul
- Regional Hospital of Mato Grosso do Sul
- Maria Aparecida Pedrossian University Hospital
| | | | | | | | - Bruna Abdul Ahad Saad
- Graduate Program in Infectious and Parasitic Diseases of Federal University of Mato Grosso do Sul
- Regional Hospital of Mato Grosso do Sul
| | - Caroline Franciscato
- Graduate Program in Infectious and Parasitic Diseases of Federal University of Mato Grosso do Sul
- Maria Aparecida Pedrossian University Hospital
| | | | | | - James Venturini
- School of Medicine at Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
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Kassegne L, Bourgarit A, Fraisse P. [Parardoxical reaction following tuberculosis treatment in non HIV-infected patients]. Rev Mal Respir 2020; 37:399-411. [PMID: 32386802 DOI: 10.1016/j.rmr.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 12/10/2019] [Indexed: 11/17/2022]
Abstract
A paradoxical reaction is the worsening of prior existing, or the appearance of, new tuberculous lesions, following the initiation of treatment with anti-tuberculous drugs, after the exclusion of poor compliance, malabsorption, drug interaction or multiresistant mycobacteria. Well known and well managed in the context of HIV coinfection, it is not well known outside this context. An increasing number of publications have described this syndrome. This review aims to describe the pathogenic, epidemiological, clinical, prognostic and therapeutic elements of non-HIV-associated paradoxical reactions. It involves a reversal of the Mycobacterium tuberculosis-induced immunodepression along with a heightened detrimental pro-inflammatory profile caused by efficient drug treatment. Extra-thoracic locations, especially lymph nodes and neurological, malnutrition and initial lymphopenia are the principal risk factors. The median delay is 40±20 days after the onset of treatment. Corticosteroids are the mainstay of the management. Anti-TNF-α drugs show good results in corticosteroid refractory cases. The prognosis is good overall except in neurological forms. The place of preventive methods remains to be established.
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Affiliation(s)
- L Kassegne
- Service de pneumologie, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg cedex, France.
| | - A Bourgarit
- Université Paris 13, Bobigny, France; Service de médecine interne, hôpital Jean-Verdier, HUPSSD AP-HP, Bondy, France; Inserm U1135, centre d'immunologie et des maladies infectieuses, 75013 Paris, France
| | - P Fraisse
- Service de pneumologie, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg cedex, France; Groupe pour l'enseignement et la recherche en pneumo-infectiologie de la SPLF, 66, boulevard Saint-Michel, 75006 Paris, France
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50
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Done MM, Akkerman OW, Al-Kailany W, de Lange WCM, de Jonge G, Kleinnijenhuis J, Stienstra R, van der Werf TS. Corticosteroid therapy for the management of paradoxical inflammatory reaction in patients with pulmonary tuberculosis. Infection 2020; 48:641-645. [PMID: 32333368 PMCID: PMC7394936 DOI: 10.1007/s15010-020-01430-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/15/2020] [Indexed: 11/04/2022]
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. Case We 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 Conclusions The 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.
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Affiliation(s)
- Macky M Done
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wud Al-Kailany
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wiel C M de Lange
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gonda de Jonge
- Department of Medical Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanneke Kleinnijenhuis
- Department of Internal Medicine, Division of Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Riejanne Stienstra
- Department of Internal Medicine, Division of Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tjip S van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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