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Hermans SM, Akkerman OW, Meintjes G, Grobusch MP. Post-tuberculosis treatment paradoxical reactions. Infection 2024:10.1007/s15010-024-02310-0. [PMID: 38955990 DOI: 10.1007/s15010-024-02310-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
Paradoxical reactions (PR) to tuberculosis (TB) treatment are common during treatment, but have also been described after treatment. A presentation with recurrent signs or symptoms of TB after cure or completion of prior treatment needs to be differentiated between microbiological relapse and a paradoxical reaction. We searched all published literature on post-treatment PR, and present a synthesis of 30 studies, focusing on the epidemiology, diagnosis and management of this phenomenon. We report an additional case vignette. The majority of studies were of lymph node TB (LN-TB), followed by central nervous system TB (CNS-TB). A total of 112 confirmed and 42 possible post-treatment PR cases were reported. The incidence ranged between 3 and 14% in LN-TB and was more frequent than relapses, and between 0 and 2% in all TB. We found four reports of pulmonary or pleural TB post-treatment PR cases. The incidence did not differ by length of treatment, but was associated with younger age at initial diagnosis, and having had a PR (later) during treatment. Post-treatment PR developed mainly within the first 6 months after the end of TB treatment but has been reported many years later (longest report 10 years). The mainstays of diagnosis and management are negative mycobacterial cultures and anti-inflammatory treatment, respectively. Due to the favourable prognosis in LN-TB recurrent symptoms, a short period of observation is warranted to assess for spontaneous regression. In CNS-TB with recurrent symptoms, immediate investigation and anti-inflammatory treatment with the possibility of TB retreatment should be undertaken.
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Affiliation(s)
- Sabine M Hermans
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- University Medical Centre Groningen, TB Centre Beatrixoord, University of Groningen, Groningen, The Netherlands
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Martin P Grobusch
- Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam Public Health-Global Health, Amsterdam Infection and Immunity, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Tropical Medicine, University of Tuebingen, Tübingen, Germany
- Centre de Recherches Médicales en Lambaréné (CERMEL), Lambaréné, Gabon
- Masanga Medical Research Unit (MMRU), Masanga, Sierra Leone
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Kassegne L, Bourgarit A, Fraisse P. [Parardoxical reaction following tuberculosis treatment in non HIV-infected patients]. Rev Mal Respir 2020; 37:399-411. [PMID: 32386802 DOI: 10.1016/j.rmr.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 12/10/2019] [Indexed: 11/17/2022]
Abstract
A paradoxical reaction is the worsening of prior existing, or the appearance of, new tuberculous lesions, following the initiation of treatment with anti-tuberculous drugs, after the exclusion of poor compliance, malabsorption, drug interaction or multiresistant mycobacteria. Well known and well managed in the context of HIV coinfection, it is not well known outside this context. An increasing number of publications have described this syndrome. This review aims to describe the pathogenic, epidemiological, clinical, prognostic and therapeutic elements of non-HIV-associated paradoxical reactions. It involves a reversal of the Mycobacterium tuberculosis-induced immunodepression along with a heightened detrimental pro-inflammatory profile caused by efficient drug treatment. Extra-thoracic locations, especially lymph nodes and neurological, malnutrition and initial lymphopenia are the principal risk factors. The median delay is 40±20 days after the onset of treatment. Corticosteroids are the mainstay of the management. Anti-TNF-α drugs show good results in corticosteroid refractory cases. The prognosis is good overall except in neurological forms. The place of preventive methods remains to be established.
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Affiliation(s)
- L Kassegne
- Service de pneumologie, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg cedex, France.
| | - A Bourgarit
- Université Paris 13, Bobigny, France; Service de médecine interne, hôpital Jean-Verdier, HUPSSD AP-HP, Bondy, France; Inserm U1135, centre d'immunologie et des maladies infectieuses, 75013 Paris, France
| | - P Fraisse
- Service de pneumologie, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg cedex, France; Groupe pour l'enseignement et la recherche en pneumo-infectiologie de la SPLF, 66, boulevard Saint-Michel, 75006 Paris, France
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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.
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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
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Ninomiya A, Saito A, Ishida T, Inoue T, Inoue T, Ezura M, Suzuki S, Uenohara H, Tominaga T. A surgical case of cerebellar tuberculoma caused by a paradoxical reaction while on therapy for tuberculosis spondylitis. Surg Neurol Int 2019; 10:162. [PMID: 31528497 PMCID: PMC6744749 DOI: 10.25259/sni_318_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/04/2019] [Indexed: 12/15/2022] Open
Abstract
Background: A paradoxical reaction (PR) is a phenomenon in which the primary tuberculous lesion worsens or another de novo tuberculous lesion appears while on anti-tuberculosis therapy. Here, we report a rare case of cerebellar tuberculoma caused by a PR during therapy for lumbar tuberculous spondylitis (Pott’s disease). Case Description: A 47-year-old male with human immunodeficiency virus seronegative was diagnosed with lumber tuberculous spondylitis (Pott’s disease) and prescribed anti-tuberculous agents. His lower back pain and inflammatory condition recovered after initiation of anti-tuberculous therapy. Two months later, he complained of headache, nausea, and staggering. Magnetic resonance images revealed a ring-enhanced lesion located at the cerebellar hemisphere extending to the vermis, which caused perifocal edema and bilateral ventriculomegaly. These findings were consistent with his symptoms of hydrocephalus. He did not have preceding clinical findings of meningitis, and a PR was suggested to cause de novo aggregation of cerebellar tuberculoma. A lesionectomy was performed, and the surgical specimen was pathologically diagnosed as a tuberculoma. He recovered well from neurological disorders after the resection. Conclusion: De novo formation of intracranial tuberculoma alone caused by a PR without preceding meningitis is very rare. Lesionectomy is needed for intracranial tuberculoma, which manifests as a mass effect, as well as antituberculous therapy.
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Affiliation(s)
- Atsuhiko Ninomiya
- Department of Neurosurgery, Sendai Medical Centre.,Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | | | | | - Tomoo Inoue
- Department of Neurosurgery, Sendai Medical Centre
| | | | | | | | | | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
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