1
|
Gusmão CC, Dos Reis R, Litvoc MN, Hirata CE, Yamamoto JH. Paradoxical Reaction in Intraocular Tuberculosis: Report of Three Cases. Ocul Immunol Inflamm 2024:1-6. [PMID: 38981076 DOI: 10.1080/09273948.2024.2372314] [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: 04/08/2024] [Accepted: 06/20/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE To present paradoxical reaction (PR) in three cases with ocular tuberculosis (OTB) treated with antitubercular therapy (ATT), highlighting diagnostic challenges and treatment strategies. METHODS We retrospectively reviewed clinical records of three OTB patients presenting with paradoxical worsening after ATT initiation at two Brazilian university hospitals. RESULTS The patients (2 males, 1 female) experienced worsening clinical presentation (increased inflammation, vision loss) within two to three weeks after initiating ATT. One patient who was HIV-positive with unilateral multifocal choroiditis developed PR soon after starting antiretroviral therapy. The second patient presented with a choroidal tuberculoma in both eyes. The third patient also had multifocal choroiditis and developed a localized choroidal elevation with a double-layer sign as a manifestation of PR. All patients were maintained on ATT therapy in association with corticosteroids and experienced improvement of inflammatory signs. CONCLUSION This case series highlights the potential for PR in OTB patients. Close monitoring and prompt therapeutic adjustments are crucial for management success.
Collapse
Affiliation(s)
- Camillo Carneiro Gusmão
- Faculdade de Medicina, LIM 33, Department of Ophthalmology, Universidade de São Paulo, São Paulo, Brazil
- Faculdade de Ciências Médicas, Department of Ophthalmology, Universidade Estadual de Campinas, Campinas, Brazil
| | - Roberto Dos Reis
- Faculdade de Medicina, LIM 33, Department of Ophthalmology, Universidade de São Paulo, São Paulo, Brazil
- Faculdade de Ciências Médicas, Department of Ophthalmology, Universidade Estadual de Campinas, Campinas, Brazil
| | - Marcelo Nóbrega Litvoc
- Faculdade de Medicina, Division of Infectious Diseases, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Hirata
- Faculdade de Medicina, LIM 33, Department of Ophthalmology, Universidade de São Paulo, São Paulo, Brazil
| | - Joyce Hisae Yamamoto
- Faculdade de Medicina, LIM 33, Department of Ophthalmology, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Choe J, Han A, Shin SH, Lee K, Um SW, Kim H, Kim TY, Huh HJ, Choi YL, Han J, Jeong BH. Clinical Course of Patients With Mediastinal Lymph Node Tuberculosis and Risk Factors for Paradoxical Responses. J Korean Med Sci 2023; 38:e348. [PMID: 38050909 PMCID: PMC10695755 DOI: 10.3346/jkms.2023.38.e348] [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: 04/10/2023] [Accepted: 09/07/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Paradoxical responses (PR) occur more frequently in lymph node tuberculosis (LNTB) than in pulmonary tuberculosis and present difficulties in differential diagnosis of drug resistance, new infection, poor patient compliance, and adverse drug reactions. Although diagnosis of mediastinal LNTB has become much easier with the development of endosonography, limited information is available. The aim of this study was to investigate the clinical course of mediastinal LNTB and the risk factors associated with PR. METHODS Patients diagnosed with mediastinal LNTB via endosonography were evaluated retrospectively between October 2009 and December 2019. Multivariable logistic regression was applied to evaluate the risk factors associated with PR. RESULTS Of 9,052 patients who underwent endosonography during the study period, 158 were diagnosed with mediastinal LNTB. Of these, 55 (35%) and 41 (26%) concurrently had pulmonary tuberculosis and extrapulmonary tuberculosis other than mediastinal LNTB, respectively. Of 125 patients who completed anti-tuberculosis treatment, 21 (17%) developed PR at a median of 4.4 months after initiation of anti-tuberculosis treatment. The median duration of anti-tuberculosis treatment was 6.3 and 10.4 months in patients without and with PR, respectively. Development of PR was independently associated with age < 55 years (adjusted odds ratio [aOR], 5.72; 95% confidence interval [CI], 1.81-18.14; P = 0.003), lymphocyte count < 800/μL (aOR, 8.59; 95% CI, 1.60-46.20; P = 0.012), and short axis diameter of the largest lymph node (LN) ≥ 16 mm (aOR, 5.22; 95% CI, 1.70-16.00; P = 0.004) at the time of diagnosis of mediastinal LNTB. CONCLUSION As PR occurred in one of six patients with mediastinal LNTB during anti-tuberculosis treatment, physicians should pay attention to patients with risk factors (younger age, lymphocytopenia, and larger LN) at the time of diagnosis.
Collapse
Affiliation(s)
- Junsu Choe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Areum Han
- Division of Pulmonary and Allergy, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyungjong Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Won Um
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Yeul Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jae Huh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-La Choi
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joungho Han
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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
| |
Collapse
|
8
|
Singh J, Saluja P, Thacker A, More A, Tripathi S, Sen A. Disseminated Tuberculosis Presenting as Ciliary Body and Thyroid Mass Lesions: A Case Report. Ocul Immunol Inflamm 2023:1-4. [PMID: 36701770 DOI: 10.1080/09273948.2022.2164730] [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: 09/20/2022] [Revised: 12/24/2022] [Accepted: 12/29/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE To report a case of disseminated TB presenting as ciliary body and thyroid mass lesions. CASE REPORT A 17-year-old male patient presented with a thyroid mass and blurring of vision in the left eye. A diagnosis of ciliary body granuloma was made. Although the Mantoux was negative, the HRCT chest showed evidence of miliary TB, and the fine needle aspiration cytology from the thyroid mass revealed AFB. On initiation of Antitubercular therapy(ATT), a paradoxical worsening of ciliary body granuloma was noted which resolved on starting steroids. CONCLUSION Involvement of thyroid gland and ciliary body although rare in tuberculosis, may be the presenting feature of disseminated TB. Paradoxical reactions seen after initiation of ATT in these cases may respond well to oral steroids.
Collapse
Affiliation(s)
- Jayanti Singh
- Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Pranav Saluja
- Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Abhiram Thacker
- Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Amruta More
- Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Shubhi Tripathi
- Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India
| | - Alok Sen
- Department of Retina and Uvea, Sadguru Netra Chikitsalaya, Chitrakoot, India
| |
Collapse
|
9
|
Christian E, Johnston A. CNS TB-IRIS Following Cessation of Adalimumab in an Adolescent with Crohn’s Disease. Open Forum Infect Dis 2022; 9:ofac367. [PMID: 35949406 PMCID: PMC9356675 DOI: 10.1093/ofid/ofac367] [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: 06/03/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022] Open
Abstract
Immune reconstitution inflammatory syndrome to tuberculosis (TB-IRIS) is an inflammatory response to M. tuberculosis infection that arises following restoration of the immune system and is increasingly recognized as a risk in patients treated with tumor necrosis factor α inhibitors who develop active tuberculosis infection. We present the case of a 19-year-old man treated with adalimumab for Crohn’s disease who presented with disseminated miliary tuberculosis. His treatment course was complicated by central nervous system TB-IRIS following cessation of his immunosuppression. We review the presentation and differential diagnosis of TB-IRIS, as well as risk factors for developing IRIS and the treatment of IRIS in this population.
Collapse
Affiliation(s)
- Elizabeth Christian
- Division of Infectious Disease, Boston Children’s Hospital , Boston, MA , USA
- Infectious Disease, Beth Israel Deaconess Medical Center , Boston, MA , USA
| | - Alicia Johnston
- Division of Infectious Disease, Beth Israel Deaconess Medical Center , Boston, MA , USA
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| | | | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Sarfaraz S, Iftikhar S, Salahuddin N. Frequency, clinical characteristics, risks, and outcomes of Paradoxical upgrading reactions during anti-tuberculosis treatment in tuberculous lymphadenitis. Pak J Med Sci 2020; 36:S27-S32. [PMID: 31933603 PMCID: PMC6943110 DOI: 10.12669/pjms.36.icon-suppl.1711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To investigate the clinical characteristics, risks and outcomes of Paradoxical upgrading reactions (PUR) during anti-tuberculosis treatment (ATT) in superficial tuberculous lymphadenitis (TBLA). Methods In this nested case-control study, all patients diagnosed with TBLA based on combinations of histopathology, acid-fast bacilli (AFB) microscopy, AFB culture, and GeneXpert, between February 2013 and April 2016, were enrolled. Standard ATT was given. Demographics, clinical characteristics, occurrence of PUR and outcome were recorded. Results TBLA was diagnosed and treated in 189 patients. PUR developed in 33 (17%), of which 77% developed new inflamed glands, 20.6% had increased size and inflammation of pre-existing glands and 5.9% had superficial chest wall abscesses requiring aspiration. All responded to regular NSAIDs except one, where a steroid course was effective. No change in dose or duration of ATT was required. Presence of anorexia (OR; 95%CI: 2.6; 1.003-6.74), bilateral extensive lymphadenopathy (OR; 95%CI: 2.9; 1.1-7.5) and lymph node specimen positive for AFB (OR; 95%CI: 3.2; 1.04-10.1) were significantly associated with PUR. Conclusion PUR is common in TBLA. It responded to NSAIDS and does not need any modification in ATT.
Collapse
Affiliation(s)
- Samreen Sarfaraz
- Samreen Sarfaraz, MRCP. Infectious Disease Department, The Indus Hospital, Karachi, Pakistan
| | - Sundus Iftikhar
- Sundus Iftikhar, MPhil. Indus Hospital Research Center, The Indus Hospital, Karachi, Pakistan
| | - Naseem Salahuddin
- Naseem Salahuddin, D.A.B.I.M. Infectious Disease Department, The Indus Hospital, Karachi, Pakistan
| |
Collapse
|
20
|
Aggarwal D, Bhardwaj M, Kumar A, Saini V, Sawal N. Immune reconstitution inflammatory syndrome in non-HIV patients with tuberculosis. A case series. Indian J Tuberc 2020; 67:143-147. [PMID: 32192610 DOI: 10.1016/j.ijtb.2019.02.018] [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: 01/03/2019] [Accepted: 02/28/2019] [Indexed: 06/10/2023]
Abstract
Tuberculosis associated Immune reconstitution inflammatory syndrome (IRIS) in a HIV negative patient can present with a multitude of clinic-radiological presentations that are often confused with drug resistance/treatment failure. Being a diagnosis of exclusion, this clinical entity is often prone to under-diagnosis. We present a series of 5 patients who presented with varied but uncommon IRIS manifestations. High index of suspicion coupled with clinical reasoning and judicious use of phenotypic and genotypic culture methods helped in their timely detection and successful treatment.
Collapse
Affiliation(s)
- Deepak Aggarwal
- Associate Professor, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India.
| | - Manisha Bhardwaj
- Ex-Senior Resident, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| | - Arjun Kumar
- Junior Resident, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| | - Varinder Saini
- Professor & Head, Dept of Pulmonary Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| | - Nishit Sawal
- Assistant Professor, Dept of General Medicine, Govt Medical College & Hospital, Sector-32, Chandigarh, 160030, India
| |
Collapse
|
21
|
Treatment with Tumor Necrosis Factor-α Inhibitors, History of Allergy, and Hypercalcemia Are Risk Factors of Immune Reconstitution Inflammatory Syndrome in HIV-Negative Pulmonary Tuberculosis Patients. J Clin Med 2019; 9:jcm9010096. [PMID: 31905985 PMCID: PMC7019635 DOI: 10.3390/jcm9010096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/27/2019] [Indexed: 12/15/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an immune reaction that occurs along with the recovery of the patient’s immunity. Tuberculosis-related IRIS (TB-IRIS) upon tumor necrosis factor (TNF)-α inhibitor treatment has been reported in non-human immunodeficiency virus (HIV) patients. However, the importance of biological treatment, as a risk factor of IRIS, has not yet been established. In this study, we examined TB-IRIS in non-HIV patients to explore the role of TNF-α inhibitor treatment. Out of 188 patients with pulmonary TB, seven patients had IRIS. We examined univariate logistic and multivariate analysis to elucidate risk factors of TB-IRIS. Univariate analysis indicated that usage of immunosuppressive drugs, TNF-α inhibitors, and history of food or drug allergy were significantly related with TB-IRIS. On initial treatment, the values of serological markers such as serum albumin and serum calcium were significantly related with TB-IRIS. There was a higher mortality rate in patients with TB-IRIS. Furthermore, multivariate analysis revealed that usage of TNF-α inhibitors, history of allergy, and serum hypercalcemia were related to TB-IRIS. Usage of TNF-α inhibitors, history of allergy, and serum hypercalcemia may be independent predictors of TB-IRIS in non-HIV patients. Since higher mortality has been reported for TB-IRIS, we should pay attention to TB patients with these risk factors.
Collapse
|
22
|
Guo T, Guo W, Song M, Ni S, Luo M, Chen P, Peng H. Paradoxical Reaction In The Form Of New Pulmonary Mass During Anti-Tuberculosis Treatment: A Case Series And Literature Review. Infect Drug Resist 2019; 12:3677-3685. [PMID: 32063717 PMCID: PMC6884965 DOI: 10.2147/idr.s211556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/30/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction Paradoxical reaction refers to deterioration of the original tuberculosis lesions or emergence of new infiltrative lesions during anti-tuberculosis treatment. The common manifestations of paradoxical reaction include new pleural effusion, cerebral tuberculosis and lymphadenitis. Paradoxical reaction manifested by new pulmonary mass is rare. Patients and methods This article summarizes and analyzes the clinical manifestations, chest CT, laboratory findings, treatments, pathological biopsy results of five patients diagnosed as paradoxical reaction in the form of new pulmonary mass. A literature review related to paradoxical reaction was conducted. Results Five patients diagnosed as pulmonary tuberculosis or tuberculous pleuritis received systematic anti-tuberculosis treatmensssts. New pulmonary masses were found by CT scans during the follow-ups. The patients were negative for tumor markers, examination of rheumatoid connective tissue disease and G/GM test. The original anti-tuberculosis treatments were continued. All of the masses were diminished gradually. Conclusion Paradoxical reaction needs to be taken into consideration when a new pulmonary mass occurs during anti-tuberculosis treatments. The diagnosis should be based on the patients’ clinical manifestations, laboratory results, imaging examinsssations and lung biopsy examinations. The original anti-tuberculosis therapy can be continued in patients without severe clinical symptoms. A close follow-up is needed.
Collapse
Affiliation(s)
- Ting Guo
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| | - Wei Guo
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| | - Min Song
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| | - Shanshan Ni
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| | - Man Luo
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| | - Ping Chen
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| | - Hong Peng
- Department of Respiratory and Critical Care Medicine, The Second Xiangya Hospital of Central-South University, Changsha, Hunan 410011, People's Republic of China.,Research Unit of Respiratory Disease, Central-South University, Changsha, Hunan 410011, People's Republic of China.,The Respiratory Disease Diagnosis and Treatment Center of Hunan Province, Changsha, Hunan 410011, People's Republic of China
| |
Collapse
|
23
|
Ganesh SK, Abraham S, Sudharshan S. Paradoxical reactions in ocular tuberculosis. J Ophthalmic Inflamm Infect 2019; 9:19. [PMID: 31493128 PMCID: PMC6730739 DOI: 10.1186/s12348-019-0183-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 08/09/2019] [Indexed: 12/18/2022] Open
Abstract
Paradoxical reactions following initiation of anti-tubercular therapy have been documented most often in extrapulmonary tuberculosis. A combination of factors such as delayed hypersensitivity, decreased suppressor mechanisms, and an increased response to mycobacterial antigens mediated by the host’s immune system have been implicated in the development of these reactions. Similar worsening in patients with ocular tuberculosis while on treatment has been described. It is therefore important for the clinician to be aware of this occurrence, as prompt recognition and timely institution of corticosteroids and immunosuppressants can lead to restoration of vision. In these patients, an alteration or discontinuation of anti-tubercular therapy may not be indicated.
Collapse
Affiliation(s)
- Sudha K Ganesh
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, India.
| | - Sharanya Abraham
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, India
| | - Sridharan Sudharshan
- Medical Research Foundation, Sankara Nethralaya, 18, College Road, Chennai, 600 006, India
| |
Collapse
|
24
|
Ledingham D, El-Wahsh S, Sebire D, Cappelen-Smith C, Hodgkinson SJ, McDougall AJ, Maley M, Cordato DJ. Adjuvant immunosuppression for paradoxical deterioration in tuberculous meningitis including one case responsive to cyclosporine. A tertiary referral hospital experience. J Neurol Sci 2019; 404:58-62. [PMID: 31330455 DOI: 10.1016/j.jns.2019.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 06/09/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) accounts for 1-4% of all tuberculosis (TB) presentations. Paradoxical deterioration in non-HIV patients is a common manifestation of anti-tuberculosis therapy, characterised by clinico-radiological deterioration. We report a case series of TBM admissions to our institution including one case with paradoxical deterioration refractory to corticosteroids who responded to adjuvant cyclosporine. METHODS Retrospective review of 12 HIV-negative patients admitted to Liverpool Hospital, Sydney (2005-2016) with laboratory and/or radiologically confirmed TBM. RESULTS Median patient age was 40 (range 22-81 years), M:F = 7:5. Eleven patients (92%) were of Asia-Pacific origin. Eleven initially presented with central nervous system manifestations and one had preceding miliary TB. Nine patients had extra-cranial TB involvement including eight with past or current pulmonary disease. Cerebrospinal fluid (CSF) TB PCR/culture was positive in 10 patients. Paradoxical deterioration developed in three patients despite concomitant corticosteroids in two. One patient with paradoxical deterioration was refractory to corticosteroids: A 22-year-old Vietnamese male with TBM developed worsening headaches and altered mentation after seven weeks concomitant anti-TB and corticosteroid treatment. Interval MRI brain demonstrated increased size and number of tuberculomas as well as hydrocephalus. Cyclosporine was added with gradual improvement and ultimately good outcome. CONCLUSION Our case series highlights the seriousness of paradoxical deterioration in TBM and the potential role of adjuvant cyclosporine in patients refractory to corticosteroids.
Collapse
Affiliation(s)
- D Ledingham
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia
| | - S El-Wahsh
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia
| | - D Sebire
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia
| | - C Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - S J Hodgkinson
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - A J McDougall
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - M Maley
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia; Department of Microbiology and Infectious Diseases, NSW Health Pathology Liverpool, Sydney, Australia
| | - D J Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
| |
Collapse
|
25
|
Evaluation of treatment response in extrapulmonary tuberculosis in a low-resource setting. BMC Infect Dis 2019; 19:426. [PMID: 31096926 PMCID: PMC6524265 DOI: 10.1186/s12879-019-4034-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 04/26/2019] [Indexed: 11/30/2022] Open
Abstract
Background Diagnosing extrapulmonary tuberculosis (EPTB) is challenging and many patients are initiated on empirical anti-TB treatment without a laboratory confirmed diagnosis. Monitoring treatment response is thus important to ensure correct diagnosis and proper disease management. The definition of satisfactory response to treatment in EPTB remains unclear. The objectives of this study were to describe the clinical presentation of EPTB and the effect of treatment on clinical parameters. Further, to assess if simple clinical parameters, without laboratory data, could evaluate treatment response. Methods Prospective cohort study of presumptive EPTB patients at Mnazi Mmoja Hospital, Zanzibar. By using a composite reference standard, patients were categorized as TB or non-TB cases. The TB patients were followed during anti-TB treatment. Results There were 64 TB and 62 non-TB cases. The frequency of symptoms at baseline were comparable in TB and non-TB patients, with lymphadenitis and pleuritis as the most common manifestations. Among TB cases, there was a trend towards regression of lymphadenopathy after 2 months, and at treatment completion 24/28 (86%) cases showed full regression. Weight gain ≥5% was reported in 36/49 (73%) of the TB patients at 2 months and in 38/46 (83%) at treatment completion. After 2 months of treatment, a combination of clinical parameters; improvement of symptoms (50/50), ≥5% weight gain (36/49) and regression of physical signs (45/49) correlated with the treatment response. Conclusions An algorithm including only simple clinical parameters could be used as an easy tool to assess treatment responses in low-resource settings. However, this needs to be tested on a larger sample size.
Collapse
|
26
|
Kang HS, Lee HY, Jung JI, Kim JS, Kim YH, Kim SJ, Kim SC, Kwon SS, Kim YK, Kang JY. Clinical significance of Glasgow Prognostic Score in patients with tuberculous pleurisy. J Thorac Dis 2018; 10:6077-6087. [PMID: 30622779 DOI: 10.21037/jtd.2018.10.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The Glasgow Prognostic Score (GPS) reflects the host systemic inflammatory response and is a validated, independent prognostic factor for various malignancies. We investigated the clinical significance of the GPS in patients with tuberculosis (TB) pleurisy, focusing on treatment outcomes including paradoxical response (PR). Methods This was a retrospective study performed between January 2010 and December 2015 in two referral and university hospitals in South Korea, with intermediate incidences of TB. In all, 462 patients with TB pleurisy were registered in the study. The patients were classified into three groups based on GPS score, as follows: (I) GPS of 2, elevated CRP level (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL); (II) GPS of 1, elevated CRP level or hypoalbuminemia; and (III) GPS of 0, neither elevated CRP level nor hypoalbuminemia. Results A total of 367 patients with TB pleurisy were finally included. PR occurred in 102 (27.8%) patients after a mean of 75 days following initiation of anti-TB treatment. The proportion of PR occurrence was significantly lower in the GPS 2 group (P=0.007). Successful treatment outcomes including cure and completion were also significantly lower in the GPS 2 group (P=0.001), while all-cause mortality and TB-specific mortality were higher in the GPS 2 group (P=0.001 and <0.001, respectively). Old age over than 65 years old was an independent predicting factor for high mortality and lower PR occurrence. However, the TB relapse rate was not different among the three GPS groups. Conclusions Higher GPS value and elderly age were identified as prognostic factors for poor outcomes in TB pleurisy and as predicting factors for lower PR occurrence. More prospective studies are needed to clarify the utility of GPS in patients with TB pleurisy.
Collapse
Affiliation(s)
- Hye Seon Kang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hwa Young Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Im Jung
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Sang Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Hyun Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Joon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Chan Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soon Seog Kwon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Young Kang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
27
|
Faiz S, Ettahar N, Sabbah M, Toné A, Benrezkallah M, Bourgarit A, Chopin MC. Traitement par infliximab d’une réaction paradoxale neuroméningée chez un patient immunocompétent compliquant une tuberculose ganglionnaire, pulmonaire et méningée. Med Mal Infect 2018. [DOI: 10.1016/j.medmal.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
28
|
Ko Y, Mo EK, Park YB, Kang MR, Bae JS, Kim Y. Miliary Tuberculosis Mimicking Brain Metastasis from Renal Cell Carcinoma. JOURNAL OF NEUROCRITICAL CARE 2018. [DOI: 10.18700/jnc.180045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
29
|
Barr DA, Coussens AK, Irvine S, Ritchie ND, Herbert K, Choo-Kang B, Raeside D, Bell DJ, Seaton RA. Paradoxical upgrading reaction in extra-pulmonary tuberculosis: association with vitamin D therapy. Int J Tuberc Lung Dis 2018; 21:677-683. [PMID: 28482963 PMCID: PMC5424669 DOI: 10.5588/ijtld.16.0927] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
SETTING: Glasgow, Scotland, UK. BACKGROUND: Paradoxical reactions in tuberculosis (TB) are a notable example of our incomplete understanding of host-pathogen interactions during anti-tuberculosis treatment. OBJECTIVES: To determine risk factors for a TB paradoxical reaction, and specifically to assess for an independent association with vitamin D use. DESIGN: Consecutive human immunodeficiency virus (HIV) negative adult patients treated for extra-pulmonary TB were identified from an Extended Surveillance of Mycobacterial Infections database. In our setting, vitamin D was variably prescribed for newly diagnosed TB patients. A previously published definition of paradoxical TB reaction was retrospectively applied to, and data on all previously described risk factors were extracted from, centralised electronic patient records. The association with vitamin D use was assessed using multivariate logistic regression. RESULTS: Of the 249 patients included, most had TB adenopathy; 222/249 had microbiologically and/or histologically confirmed TB. Vitamin D was prescribed for 57/249 (23%) patients; 37/249 (15%) were classified as having paradoxical reactions. Younger age, acid-fast bacilli-positive invasive samples, multiple disease sites, lower lymphocyte count and vitamin D use were found to be independent risk factors. CONCLUSION: We speculate that vitamin D-mediated signalling of pro-inflammatory innate immune cells, along with high antigenic load, may mediate paradoxical reactions in anti-tuberculosis treatment.
Collapse
Affiliation(s)
- D A Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, UK
| | - A K Coussens
- Department of Pathology, Faculty of Health Sciences, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa
| | - S Irvine
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow
| | - N D Ritchie
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow
| | | | - B Choo-Kang
- Department of Respiratory Medicine, Glasgow Royal Infirmary, Glasgow
| | | | - D J Bell
- Department of Infectious Diseases, The Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - R A Seaton
- Department of Infectious Diseases, The Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| |
Collapse
|
30
|
Thorve SM, Patil NS, Mandilwar S, Vora A. Loss of vision and hearing in a case of cervical lymph node tuberculosis: A rare paradoxical reaction. Lung India 2017; 34:573-575. [PMID: 29099011 PMCID: PMC5684823 DOI: 10.4103/lungindia.lungindia_231_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Swapnil Manaji Thorve
- Department of Pulmonary Medicine, Lokmanya Tilak Medical College, Mumbai, Maharashtra, India E-mail:
| | - Neelakanth S Patil
- Department of Medicine, SDM Medical College and Hospital, Dharwad, Karnataka, India
| | - Saurabh Mandilwar
- Department of Pulmonary Medicine, HBT Medical College, Mumbai, Maharashtra, India
| | - Agam Vora
- Department of Pulmonary Medicine, HBT Medical College, Mumbai, Maharashtra, India
| |
Collapse
|
31
|
Abstract
In HIV-infected individuals, paradoxical reactions after the initiation of antiretroviral therapy (ART) are associated with a variety of underlying infections and have been called the immune reconstitution inflammatory syndrome (IRIS). In cases of IRIS associated with tuberculosis (TB), two distinct patterns of disease are recognized: (i) the progression of subclinical TB to clinical disease after the initiation of ART, referred to as unmasking, and (ii) the progression or appearance of new clinical and/or radiographic disease in patients with previously recognized TB after the initiation of ART, the classic or "paradoxical" TB-IRIS. IRIS can potentially occur in all granulomatous diseases, not just infectious ones. All granulomatous diseases are thought to result from interplay of inflammatory cells and mediators. One of the inflammatory cells thought to be integral to the development of the granuloma is the CD4 T lymphocyte. Therefore, HIV-infected patients with noninfectious granulomatous diseases such as sarcoidosis may also develop IRIS reactions. Here, we describe IRIS in HIV-infected patients with TB and sarcoidosis and review the basic clinical and immunological aspects of these phenomena.
Collapse
|
32
|
Nay MA, Barbier F. Tuberculose chez les patients de réanimation. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1268-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
33
|
Bhattacharya A, Mukherjee S. Paradoxical reaction in the form of pleural effusion after onset of anti-tuberculous medication for tubercular lymphadenitis. Clin Med (Lond) 2017; 17:143-145. [PMID: 28365625 PMCID: PMC6297614 DOI: 10.7861/clinmedicine.17-2-143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present the case of a 26-year-old Indian male who developed pleural effusion while undergoing treatment for tuberculous lymphadenitis. We describe the work-up for his condition and how he was managed. The possibility of development of a paradoxical reaction in the form of pleural effusion after initiation of anti-tuberculous therapy has to be kept in mind while treating such patients.
Collapse
Affiliation(s)
- Ambarish Bhattacharya
- Department of Medicine, TechnoIndia DAMA Hospital and Medical research center, Kolkata, India
| | - Suranjan Mukherjee
- Department of Respiratory Medicine, AMRI Hospitals Dhakuria, Kolkata, India
| |
Collapse
|
34
|
|
35
|
Bacha S, Khemiri M, Racil H, Hantous S, Chaouch N, Cheikhrouhou S, Chabbou A, Megdiche ML. [Paradoxical reaction following antituberculosis therapy in immunocompetent patient]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:367-372. [PMID: 27776947 DOI: 10.1016/j.pneumo.2016.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 08/27/2016] [Accepted: 09/17/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION The features of paradoxical reactions (PR) that occurred in non-HIV infected patients are rare and not well known. CASE REPORT The authors reported the case of a 21years old, non-immunocompromised, and HIV negative patient treated for disseminated tuberculosis. PR occurred after 8months after initiation of antituberculous treatment. PR presented as left cervical lymphadenopathy, pulmonary, pleural, costal and spinal location of the tuberculosis. The antituberculous drugs were prolonged. Patient's clinical symptoms improved initially. However, left inguinal lymphadenopathy appeared after 20months of antituberculous therapy. Inguinal lymph node biopsy revealed tuberculous lymphadenitis. The patient has a good compliance to the treatment. The patient was continued on same antituberculous treatment for a total of 28months. The cervical and inguinal lymphadenopathy disappeared and CT scan showed regression of thoracic, abdominal, costal and spinal lesions. CONCLUSION PR during antituberculous treatment must be considered after exclusion of other causes. No consensus on the therapeutic management of this entity has been developed to date.
Collapse
Affiliation(s)
- S Bacha
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie.
| | - M Khemiri
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie
| | - H Racil
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie
| | - S Hantous
- Service de radiologie, hôpital Abderrahmane Mami, Ariana, Tunisie
| | - N Chaouch
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie
| | - S Cheikhrouhou
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie
| | - A Chabbou
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie
| | - M L Megdiche
- Service de pneumologie, hôpital Abderrahmane Mami, pavillon 2 Ariana, Tunisie
| |
Collapse
|
36
|
Abstract
We sought to determine the incidence and clinical spectrum of the paradoxical reaction (PR) to treatment in 1000 children with tuberculosis (TB). Its incidence was 3.3%, presenting as mediastinal adenopathy (n = 12), central nervous system (CNS) tuberculoma (n = 8), increasing size of lymph nodes (n = 8) and serositis (n = 5). Symptoms included breathlessness (n = 7, 21.2%), neck swellings (n = 5, 15.2%), hemiplegia (n = 3, 9.1%), raised intracranial tension (n = 2, 6.1%) and fever or diabetes insipidus (n = 1, 3% each). The mean age of onset of PR was 3.5 months after the start of anti-TB medication. PR was seen predominantly in boys. Mediastinal lymphadenopathy was more common in children aged <2 years. Tuberculomas were more common in children aged 2-5 years. Nodal enlargement and serositis were seen equally in all age groups.
Collapse
Affiliation(s)
- Ira Shah
- Paediatric TB Clinic, BJ Wadia Hospital for Children, Mumbai, India
| | - M V Bhaskar
- Paediatric TB Clinic, BJ Wadia Hospital for Children, Mumbai, India
| |
Collapse
|
37
|
Okazaki A, Watanabe S, Yoneda T, Hara J, Nishitsuji M, Nishi K, Kasahara K. Paradoxical reaction to antituberculosis therapy after 6 months of treatment for pulmonary tuberculosis: A case report. J Infect Chemother 2016; 22:748-751. [DOI: 10.1016/j.jiac.2016.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/17/2016] [Accepted: 03/25/2016] [Indexed: 11/30/2022]
|
38
|
Chahed H, Hachicha H, Berriche A, Abdelmalek R, Mediouni A, Kilani B, Amor MB, Benaissa HT, Besbes G. Paradoxical reaction associated with cervical lymph node tuberculosis: predictive factors and therapeutic management. Int J Infect Dis 2016; 54:4-7. [PMID: 27810522 DOI: 10.1016/j.ijid.2016.10.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The aims of this study were to determine predictive factors of paradoxical reaction in patients with cervical lymph node tuberculosis (TB) and to discuss the therapeutic management of this condition. MATERIALS AND METHODS A retrospective study was performed of 501 patients managed for cervical lymph node TB over a period of 12 years (from January 2000 to December 2011). Statistical data were analyzed using IBM SPSS Statistics version 20.0. RESULTS Paradoxical reaction occurred in 67 patients (13.4%), with a median delay to onset after starting TB treatment of 7 months. Lymph node size ≥3cm and associated extra-lymph node TB were independently associated with paradoxical reaction. Treatment consisted of surgical excision (71.6%), restarting quadruple therapy (10.4%), reintroduction of ethambutol (23.8%), and addition of ciprofloxacin (20.8%); steroids were given in two cases . All patients recovered after an average treatment duration of 14.91±7.03 months. CONCLUSION The occurrence of paradoxical reaction in cervical lymph node TB seems to be predicted by associated extra-lymph node TB and a swelling size ≥3cm. The treatment of paradoxical reaction remains unclear and more randomized trials are necessary to improve its management.
Collapse
Affiliation(s)
- Houda Chahed
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Otorhinolaryngology Department, Rabta Hospital, Jebel Lakhdar Bab Saadoune, 1007 Tunis, Tunisia.
| | - Hela Hachicha
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Otorhinolaryngology Department, Rabta Hospital, Jebel Lakhdar Bab Saadoune, 1007 Tunis, Tunisia
| | - Aida Berriche
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Infectious Diseases Department, Rabta Hospital, Tunis, Tunisia
| | - Rim Abdelmalek
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Infectious Diseases Department, Rabta Hospital, Tunis, Tunisia
| | - Azza Mediouni
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Otorhinolaryngology Department, Rabta Hospital, Jebel Lakhdar Bab Saadoune, 1007 Tunis, Tunisia
| | - Badreddine Kilani
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Infectious Diseases Department, Rabta Hospital, Tunis, Tunisia
| | - Mohamed Ben Amor
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Otorhinolaryngology Department, Rabta Hospital, Jebel Lakhdar Bab Saadoune, 1007 Tunis, Tunisia
| | - Hanene Tiouiri Benaissa
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Infectious Diseases Department, Rabta Hospital, Tunis, Tunisia
| | - Ghazi Besbes
- Faculty of Medicine, Université de Tunis El Manar, Tunis, Tunisia; Otorhinolaryngology Department, Rabta Hospital, Jebel Lakhdar Bab Saadoune, 1007 Tunis, Tunisia
| |
Collapse
|
39
|
Rajendra A, Sabnis K, Jeyaseelan V, Rupali P. Paradoxical reaction (PR) in tuberculous lymphadenitis among HIV-negative patients: retrospective cohort study. Postgrad Med J 2016; 92:684-685. [PMID: 27638382 DOI: 10.1136/postgradmedj-2016-134326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Akhil Rajendra
- Department of General Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Kirti Sabnis
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
40
|
Brown CS, Smith CJ, Breen RAM, Ormerod LP, Mittal R, Fisk M, Milburn HJ, Price NM, Bothamley GH, Lipman MCI. Determinants of treatment-related paradoxical reactions during anti-tuberculosis therapy: a case control study. BMC Infect Dis 2016; 16:479. [PMID: 27600661 PMCID: PMC5013570 DOI: 10.1186/s12879-016-1816-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inflammatory response following initial improvement with anti-tuberculosis (TB) treatment has been termed a paradoxical reaction (PR). HIV co-infection is a recognised risk, yet little is known about other predictors of PR, although some biochemical markers have appeared predictive. We report our findings in an ethnically diverse population of HIV-infected and uninfected adults. METHODS Prospective and retrospective clinical and laboratory data were collected on TB patients seen between January 1999-December 2008 at four UK centres selected to represent a wide ethnic and socio-economic mix of TB patients. Data on ethnicity and HIV status were obtained for all individuals. The associations between other potential risk factors and PR were assessed in a nested case-control study. All PR cases were matched two-to-one to controls by calendar time and centre. RESULTS Of 1817 TB patients, 82 (4.5 %, 95 % CI 3.6-5.5 %) were identified as having a PR event. The frequency of PR was 14.4 % (18/125; 95 % CI 8.2-20.6 %) and 3.8 % (64/1692; 2.9-4.7) for HIV-positive and HIV-negative individuals respectively. There were no differences observed in PR frequency according to ethnicity, although the site was more likely to be pulmonary in those of black and white ethnicity, and lymph node disease in those of Asian ethnicity. In multivariate analysis of the case-control cohort, HIV-positive patients had five times the odds of developing PR (aOR = 5.05; 95 % CI 1.28-19.85, p = 0.028), whilst other immunosuppression e.g. diabetes, significantly reduced the odds of PR (aOR = 0.01; 0.00-0.27, p = 0.002). Patients with positive TB culture had higher odds of developing PR (aOR = 6.87; 1.31-36.04, p = 0.045) compared to those with a negative culture or those in whom no material was sent for culture. Peripheral lymph node disease increased the odds of a PR over 60-fold 4(9.60-431.25, p < 0.001). CONCLUSION HIV was strongly associated with PR. The increased potential for PR in people with culture positive TB suggests that host mycobacterial burden might be relevant. The increased risk with TB lymphadenitis may in part arise from the visibility of clinical signs at this site. Non-HIV immunosuppression may have a protective effect. This study highlights the difficulties in predicting PR using routinely available demographic details, clinical symptoms or biochemical markers.
Collapse
Affiliation(s)
- Colin Stewart Brown
- Hospital for Tropical Diseases, University College London Hospitals Foundation Trust, 235 Euston Road, London, NW1 2BU, UK.,UCL Division of Infection and Immunity, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Colette Joanne Smith
- Royal Free Campus, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | | | | | - Rahul Mittal
- Royal Blackburn Hospital, Blackburn, Lancs, BB2 3LR, UK
| | - Marie Fisk
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Heather June Milburn
- Guy's and St Thomas' Hospital NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nicholas Martin Price
- Guy's and St Thomas' Hospital NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | | | - Marc Caeroos Isaac Lipman
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK. .,UCL Respiratory, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK.
| |
Collapse
|
41
|
Kang HK, Jeong BH, Lee H, Park HY, Jeon K, Huh HJ, Ki CS, Lee NY, Koh WJ. Clinical significance of smear positivity for acid-fast bacilli after ≥5 months of treatment in patients with drug-susceptible pulmonary tuberculosis. Medicine (Baltimore) 2016; 95:e4540. [PMID: 27495111 PMCID: PMC4979865 DOI: 10.1097/md.0000000000004540] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with pulmonary tuberculosis (TB) with acid-fast bacilli (AFB)-positive sputum smear at 5 months or later during treatment are considered to be cases of treatment failure according to World Health Organization guidelines. This study evaluated the proportion, clinical characteristics, and significance of positive sputum smears after ≥5 months of standard treatment in patients with drug-susceptible pulmonary TB.This was a retrospective cohort study of 1611 patients with culture-confirmed drug-susceptible pulmonary TB who received standard anti-TB treatment from January 2009 to February 2014. Forty-one patients (2.5%) who were smear-positive after ≥5 months of treatment and 123 age- and sex-matched control patients were evaluated.Among the 41 smear-positive patients, culture of the sputum specimens yielded Mycobacterium tuberculosis (MTB) in 1 patient (2.4%), nontuberculous mycobacteria (NTM) in 7 (17.1%), and no growth in the remaining 33 patients (80.5%). Treatment was successfully completed in 40 patients (97.6%) with prolongation of the continuation phase regimens without change to second-line anti-TB treatment. In patients with smear positivity after ≥5 months of treatment compared with controls, cavitation on chest radiographs (53.7% vs. 25.2%, P = 0.001), bilateral involvement (51.2% vs. 30.1%, P = 0.01) and combined pleural effusion (26.8% vs. 10.6%, P = 0.01) were found more frequently at the time of treatment initiation, and paradoxical response occurred more commonly (19.5% vs. 3.3%, P = 0.002) during treatment.Smear-positive sputum after ≥5 months of standard anti-TB treatment was mainly because of nonviable MTB bacilli or NTM in patients with drug-susceptible pulmonary TB. AFB smear alone should not be used to assess treatment failure and careful examination of microbiologic status, including culture and drug susceptibility testing, is needed before making changes to retreatment regimens or empirical second-line anti-TB regimens in these patients.
Collapse
Affiliation(s)
- Hyung Koo Kang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, Gyeonggi
| | - Byeong-Ho Jeong
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Hyun Lee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Hye Yun Park
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Kyeongman Jeon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Hee Jae Huh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chang-Seok Ki
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won-Jung Koh
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
- Correspondence: Won-Jung Koh, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, South Korea (e-mail: )
| |
Collapse
|
42
|
Shah I, Goyal A. Childhood multi-drug resistant tuberculosis with paradoxical granulomas - role of steroids. Infect Dis (Lond) 2016; 48:862-3. [PMID: 27376454 DOI: 10.1080/23744235.2016.1203986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Ira Shah
- a Pediatric TB Clinic , B.J.Wadia Hospital for Children , Mumbai , India
| | - Anmol Goyal
- a Pediatric TB Clinic , B.J.Wadia Hospital for Children , Mumbai , India
| |
Collapse
|
43
|
Singh AK, Malhotra HS, Garg RK, Jain A, Kumar N, Kohli N, Verma R, Sharma PK. Paradoxical reaction in tuberculous meningitis: presentation, predictors and impact on prognosis. BMC Infect Dis 2016; 16:306. [PMID: 27329253 PMCID: PMC4915108 DOI: 10.1186/s12879-016-1625-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 06/07/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Awareness about paradoxical reactions in tuberculous meningitis is crucial as a paradoxical reaction may lead to certain wrong conclusions (for example, an erroneous diagnosis, and a possibility of treatment failure, mycobacterial drug-resistance, drug toxicity, or presence of a malignancy). The present study was planned to evaluate the incidence and predictive factors of paradoxical reactions in light of clinical, cerebrospinal fluid, and neuroimaging characteristics. METHODS In this prospective cohort study, consecutive patients fulfilling the International Consensus criteria of tuberculous meningitis were included. Patients were subjected to clinical evaluation, cerebrospinal fluid evaluation, and neuroimaging. Patients were treated with anti-tuberculosis drugs along with corticosteroids. Patients were regularly followed up at 3 monthly intervals. At each follow up patients were evaluated clinically and repeat cerebrospinal fluid analysis was performed along with repeat neuroimaging. Disability assessment was done using Barthel index. RESULTS We enrolled 141 patients of tuberculous meningitis. Approximately one-third of patients (44/141; 31.2 %) developed a paradoxical reaction. Twenty-seven patients developed hydrocephalus, 26 developed tuberculomas, 12 developed optochiasmatic arachnoiditis and 4 patients had spinal arachnoiditis. In 41 patients (out of 44) cerebrospinal fluid paradoxically worsened (increase in cells and/or protein); 2 demonstrated a decrease in cells with polymorph predominance while in one it was normal. In 3 patients, paradoxical cerebrospinal fluid changes were not associated with neuroimaging changes. On multivariate analysis, predictors of paradoxical reaction were female gender (p = 0.013), HIV positivity (p = 0.01) and a shorter duration of illness (p = 0.049). Development of paradoxical reactions did not predict the disability status of the patients. CONCLUSIONS Paradoxical reaction occurs in approximately one-third of patients with tuberculous meningitis. Female gender, concomitant HIV infection, and a shorter duration of illness were significant predictors. Paradoxical reactions did not adversely affect the outcome.
Collapse
Affiliation(s)
- Anurag Kumar Singh
- />Department of Neurology, King George Medical University, Uttar Pradesh Lucknow, PIN-226003 India
| | - Hardeep Singh Malhotra
- />Department of Neurology, King George Medical University, Uttar Pradesh Lucknow, PIN-226003 India
| | - Ravindra Kumar Garg
- />Department of Neurology, King George Medical University, Uttar Pradesh Lucknow, PIN-226003 India
| | - Amita Jain
- />Department of Microbiology, King George Medical University, Uttar Pradesh Lucknow, India
| | - Neeraj Kumar
- />Department of Neurology, King George Medical University, Uttar Pradesh Lucknow, PIN-226003 India
| | - Neera Kohli
- />Department of Radiodiagnosis, King George Medical University, Uttar Pradesh Lucknow, India
| | - Rajesh Verma
- />Department of Neurology, King George Medical University, Uttar Pradesh Lucknow, PIN-226003 India
| | - Praveen Kumar Sharma
- />Department of Neurology, King George Medical University, Uttar Pradesh Lucknow, PIN-226003 India
| |
Collapse
|
44
|
Shinohara T, Kagawa K, Okano Y, Sawada T, Kobayashi T, Takikawa M, Iwahara Y, Ogushi F. Disseminated tuberculosis after pregnancy progressed to paradoxical response to the treatment: report of two cases. BMC Infect Dis 2016; 16:284. [PMID: 27297079 PMCID: PMC4906776 DOI: 10.1186/s12879-016-1624-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 06/07/2016] [Indexed: 11/17/2022] Open
Abstract
Background Early postpartum women are more likely to develop tuberculosis than nonpregnant women mainly due to immune reconstitution after delivery. Paradoxical response (PR) during antituberculosis treatment also arises via recovery from immunosuppression. However, no study focused on PR during antituberculosis treatment in a postpartum patient has been reported. Case presentation We present two sequential cases (Patient 1: 26-year-old; Patient 2: 29-year-old) of postpartum tuberculosis with pulmonary and extrapulmonary lesions (Patient 1: peritonitis; Patient 2: psoas abscess secondary to spondylitis). Both cases progressed to PR (worsening of pre-existing lung infiltrations (Patients 1, 2) and new contralateral effusion (Patient 2)) in a relatively short time after initiation of treatment (Patient 1: 1 week; Patient 2: 3 weeks), suggesting that immune modulations during pregnancy and delivery may contribute to the pathogenesis of both disseminated tuberculosis and its PR. The pulmonary lesions and effusion of both cases gradually improved without change of chemotherapy regimen. Conclusion Physicians should recognize PR in tuberculosis patients with postpartum and then evaluate treatment efficacy.
Collapse
Affiliation(s)
- Tsutomu Shinohara
- Department of Clinical Investigation, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan.
| | - Kozo Kagawa
- Division of Pulmonary Medicine, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| | - Yoshio Okano
- Division of Pulmonary Medicine, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| | - Toru Sawada
- Division of Thoracic Surgery, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| | - Tooru Kobayashi
- Division of Orthopaedic Surgery, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| | - Masaya Takikawa
- Division of Obstetrics and Gynecology, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| | - Yoshihito Iwahara
- Division of Hematology, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| | - Fumitaka Ogushi
- Division of Pulmonary Medicine, National Hospital Organization Kochi Hospital, 1-2-25 Asakuranishimachi, Kochi, 780-8077, Japan
| |
Collapse
|
45
|
Abstract
Background: Patients with spinal tuberculosis started on antituberculous treatment (ATT) empirically and showing increasing size of the lesion on follow-up are a treatment challenge. We describe our experience in managing such cases. Materials and Methods: We treated 80 patients with spinal tuberculosis at our institute from January 2012 to June 2014. Of these, 50 were managed by surgical intervention and the rest 30 were managed conservatively only on anti-tubercular drugs. Six patients out of these 30 patients, showed a paradoxical increase in the size of lesion without any neurological deficits after 3 months of starting ATT. Surgical intervention was done in three cases, whereas other three were managed by ultrasound-guided tapping of the lesion with continuation of ATT. Results: There was an improvement in the symptoms with weight gain and normalcy of appetite. However, all these patients had lymphopenia on differential leukocyte counts at the outset which normalized at 3 months. Conclusion: The mainstay of management of paradoxical response in spinal tuberculosis should be conservative with drainage or aspiration of abscesses along with the continuation of ATT. Surgical decompression and stabilization may be necessary in few cases who develop new neurological deficits or deformity or instability.
Collapse
Affiliation(s)
- Kiranchand Velivela
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Alugolu Rajesh
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| |
Collapse
|
46
|
Lanzafame M, Vento S. Tuberculosis-immune reconstitution inflammatory syndrome. J Clin Tuberc Other Mycobact Dis 2016; 3:6-9. [PMID: 31723680 PMCID: PMC6850228 DOI: 10.1016/j.jctube.2016.03.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 02/26/2016] [Accepted: 03/04/2016] [Indexed: 12/24/2022] Open
Abstract
Tuberculosis-immune reconstitution inflammatory syndrome is an excessive immune response against Mycobacterium tuberculosis that may occur in either HIV-infected or uninfected patients, during or after completion of anti-TB therapy. In HIV-infected patients it occurs after initiation of antiretroviral therapy independently from an effective suppression of HIV viremia. There are two forms of IRIS: paradoxical or unmasking. Paradoxical IRIS is characterized by recurrent, new, or worsening symptoms of a treated case. Unmasking IRIS is an antiretroviral-associated inflammatory manifestation of a subclinical infection with a hastened presentation. The pathogenesis is incompletely understood and the epidemiology partially described. No specific tests can establish or rule out the diagnosis. Treatment is based on the use of anti-tuberculosis drugs sometime with adjunctive corticosteroids. Mortality is generally low.
Collapse
Affiliation(s)
| | - Sandro Vento
- Department of Medicine, School of Medicine, Nazarbayev University, Astana, Kazakhstan
| |
Collapse
|
47
|
Paradoxical anti-TNF-associated TB worsening: Frequency and factors associated with IRIS. Joint Bone Spine 2016; 83:173-8. [DOI: 10.1016/j.jbspin.2015.04.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022]
|
48
|
Bell LCK, Breen R, Miller RF, Noursadeghi M, Lipman M. Paradoxical reactions and immune reconstitution inflammatory syndrome in tuberculosis. Int J Infect Dis 2016; 32:39-45. [PMID: 25809754 DOI: 10.1016/j.ijid.2014.12.030] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/15/2014] [Accepted: 12/16/2014] [Indexed: 12/01/2022] Open
Abstract
The coalescence of the HIV-1 and tuberculosis (TB) epidemics in Sub-Saharan Africa has had a significant and negative impact on global health. The availability of effective antimicrobial treatment for both HIV-1 (in the form of highly active antiretroviral therapy (HAART)) and TB (with antimycobacterial agents) has the potential to mitigate the associated morbidity and mortality. However, the use of both HAART and antimycobacterial therapy is associated with the development of inflammatory paradoxical syndromes after commencement of therapy. These include paradoxical reactions (PR) and immune reconstitution inflammatory syndromes (IRIS), conditions that complicate mycobacterial disease in HIV seronegative and seropositive individuals. Here, we discuss case definitions for PR and IRIS, and explore how advances in identifying the risk factors and immunopathogenesis of these conditions informs our understanding of their shared underlying pathogenesis. We propose that both PR and IRIS are characterized by the triggering of exaggerated inflammation in a setting of immunocompromise and antigen loading, via the reversal of immunosuppression by HAART and/or antimycobacterials. Further understanding of the molecular basis of this pathogenesis may pave the way for effective immunotherapies for the treatment of PR and IRIS.
Collapse
Affiliation(s)
- Lucy C K Bell
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK.
| | - Ronan Breen
- Department of Respiratory Medicine, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Robert F Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, Cruciform Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Marc Lipman
- Centre for Respiratory Medicine, Royal Free London NHS Foundation Trust, University College London, London, UK
| |
Collapse
|
49
|
Soto-Hernández JL. Multiresistant Tuberculosis and Its Paradoxical Manifestations. Infect Chemother 2016; 48:225-226. [PMID: 27704732 PMCID: PMC5048005 DOI: 10.3947/ic.2016.48.3.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- José Luis Soto-Hernández
- Department of Infectious Diseases, Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Tlalpan, Mexico
| |
Collapse
|
50
|
Tai MLS, Nor HM, Kadir KAA, Viswanathan S, Rahmat K, Zain NRM, Ong KG, Rafia MH, Tan CT. Paradoxical Manifestation is Common in HIV-negative Tuberculous Meningitis. Medicine (Baltimore) 2016; 95:e1997. [PMID: 26735523 PMCID: PMC4706243 DOI: 10.1097/md.0000000000001997] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Paradoxical manifestation is worsening of pre-existing tuberculous lesion or appearance of new lesions in patients whose condition initially improved with antituberculous treatment. Our hypothesis was that paradoxical manifestation in non-HIV tuberculous meningitis (TBM) patients was underestimated and this could contribute to patients' prognosis. This was the first systemic study of paradoxical manifestation in HIV-negative TBM patients. Between 2009 and 2014, TBM patients were studied prospectively in 2 hospitals. Clinical features, cerebrospinal fluid, and radiological findings were monitored. Paradoxical manifestation was divided into definite (4 weeks or more) and probable (between 14 and 27 d) after commencement of antituberculous treatment. Forty-one non-HIV TBM patients were recruited. Definite paradoxical manifestation occurred in 23/41 (56%) of the patients. Time to onset of paradoxical manifestation was between 28 days and 9 months, and majority was between 28 and 50 days. Neuroimaging manifestation in the brain (22/41 patients, 54%) and clinical manifestation (22/41 patients, 54%) were most commonly seen, followed by cerebrospinal fluid manifestation (7/41 patients, 17%). Neuroimaging changes most commonly seen were worsening of leptomeningeal enhancement, new infarcts, new tuberculomas, and enlargement of tuberculoma. Initial Computed Tomography Angiography/magnetic resonance angiography brain showed vasculitis in 14 patients, with 2 (12.5%) showing paradoxical vasculitis during follow-up. Recurrence of the paradoxical manifestation was seen in 7/23 (30%) of the patients. More than half (14/23, 61%) of the patients improved, 6 (26%) patients died, and 3 (13%) patients had persistent neurological deficit. Paradoxical manifestation was very common in non-HIV TBM patients. Neuroimaging paradoxical manifestation of 2-4 weeks may not be paradoxical manifestation but could be delayed treatment response.
Collapse
Affiliation(s)
- Mei-Ling Sharon Tai
- From the Division of Neurology, Department of Medicine (M-LST, CTT); Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Kuala Lumpur (HMN, KAAK, KR); Department of Neurology (SV, MHR); Department of Radiology, Hospital Kuala Lumpur (NRMZ); and Department of Rehabilitation Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia (KGO)
| | | | | | | | | | | | | | | | | |
Collapse
|