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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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Azoulay LD, Houist AL, Feredj E, Vindrios W, Gallien S. [Paradoxical tuberculosis reaction]. Rev Med Interne 2024; 45:279-288. [PMID: 38267320 DOI: 10.1016/j.revmed.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
Paradoxical tuberculosis reaction is defined as the aggravation of lesions present at diagnosis or the development of new lesions under anti-tuberculosis treatment, after exclusion of other alternate causes. It affects 5 to 30% of tuberculosis patients, with a variable prevalence depending on the site of infection and the clinical background. The diagnosis of paradoxical reaction is one of elimination, and requires having ruled out therapeutic failure, notably linked to poor compliance and/or to the presence of mycobacterial antibiotic resistance. The severity of paradoxical tuberculosis reaction lies in its neurological impairment. Despite its clinical importance, the mechanisms involved remain poorly understood and its management is not consensual. Corticosteroids are the cornerstone in the medical management. The role of anti-TNF agents, currently proposed in cases of corticodependence or corticoresistance, remains to be properly defined.
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Affiliation(s)
- L-D Azoulay
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France.
| | - A-L Houist
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - E Feredj
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - W Vindrios
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
| | - S Gallien
- Service de maladies infectieuses et d'immunologie clinique, CHU de Henri-Mondor, AP-HP, Créteil, France
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Kurosaki F, Kuroki T, Nomura Y, Numao T, Bando M, Maemondo M. Prolonged paradoxical reaction requiring over 5 years of corticosteroid administration in a patient with severe tuberculous meningitis. J Infect Chemother 2024; 30:357-361. [PMID: 37922986 DOI: 10.1016/j.jiac.2023.10.027] [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: 08/17/2023] [Revised: 10/21/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
Tuberculous meningitis (TBM) is a rare disease in low-incidence countries like Japan, where general physicians have fewer experience with TBM. Despite its proper treatment and early improvement of the condition, TBM often causes paradoxical reactions (PRs), which can lead to severe complications such as stroke. As PRs in the brain are difficult to detect without regular neuroimaging surveillance and have a later onset than in other organs, delayed treatment can be fatal. We report a case of a 54-year-old, human immunodeficiency virus (HIV)-negative man who presented with TBM and miliary tuberculosis (TB) in an unconscious state. Standard anti-tuberculous therapy with adjunctive systemic high-dose dexamethasone brought rapid clinical and microbiological improvement, which allowed the dexamethasone to be tapered. However, he developed cerebral infarction with left hemiplegia due to a TBM-related PR five months after admission. Therefore, the initial high-dose dexamethasone was again added to the anti-tuberculous drugs, achieving the significant effects on the PR-related lesions. Anti-tuberculous drugs had been administered for 3 years and the dexamethasone was carefully tapered. Nevertheless, enlargement of PR-related lesions in the brain recurred 5 years later. Accordingly, the dose of corticosteroid was again increased, resulting in resolving the lesions. It is important to note that severe TBM may cause prolonged PRs, which require a long-term neuroimaging follow-up and anti-inflammatory drugs for the successful management of the TBM-related PR.
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Affiliation(s)
- Fumio Kurosaki
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan; Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan.
| | - Tomonori Kuroki
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan; Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan
| | - Yushi Nomura
- Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan
| | - Toshio Numao
- Department of Pulmonary Medicine, National Hospital Organization Utsunomiya National Hospital, Utsunomiya, Tochigi, Japan
| | - Masashi Bando
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Makoto Maemondo
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Schmitt M, Bodier T, Labarbe L, Andriamanantena D, Cabon M, Ficko C, Gominet M, Chaara T, Conan P. Suspicion d’échec d’un traitement antituberculeux à 6 mois : à propos d’un cas rare de réaction paradoxale tardive. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.10.177] [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]
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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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Marais S, Van Toorn R, Chow FC, Manesh A, Siddiqi OK, Figaji A, Schoeman JF, Meintjes G. Management of intracranial tuberculous mass lesions: how long should we treat for? Wellcome Open Res 2020; 4:158. [PMID: 32047859 PMCID: PMC6996525 DOI: 10.12688/wellcomeopenres.15501.3] [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] [Accepted: 02/21/2020] [Indexed: 12/15/2022] Open
Abstract
Tuberculous intracranial mass lesions are common in settings with high tuberculosis (TB) incidence and HIV prevalence. The diagnosis of such lesions, which include tuberculoma and tuberculous abscesses, is often presumptive and based on radiological features, supportive evidence of TB elsewhere and response to TB treatment. However, the treatment response is unpredictable, with lesions frequently enlarging paradoxically or persisting for many years despite appropriate TB treatment and corticosteroid therapy. Most international guidelines recommend a 9-12 month course of TB treatment for central nervous system TB when the infecting Mycobacterium tuberculosis ( M.tb) strain is sensitive to first-line drugs. However, there is variation in opinion and practice with respect to the duration of TB treatment in patients with tuberculomas or tuberculous abscesses. A major reason for this is the lack of prospective clinical trial evidence. Some experts suggest continuing treatment until radiological resolution of enhancing lesions has been achieved, but this may unnecessarily expose patients to prolonged periods of potentially toxic drugs. It is currently unknown whether persistent radiological enhancement of intracranial tuberculomas after 9-12 months of treatment represents active disease, inflammatory response in a sterilized lesion or merely revascularization. The consequences of stopping TB treatment prior to resolution of lesional enhancement have rarely been explored. These important issues were discussed at the 3 rd International Tuberculous Meningitis Consortium meeting. Most clinicians were of the opinion that continued enhancement does not necessarily represent treatment failure and that prolonged TB therapy was not warranted in patients presumably infected with M.tb strains susceptible to first-line drugs. In this manuscript we highlight current medical treatment practices, benefits and disadvantages of different TB treatment durations and the need for evidence-based guidelines regarding the treatment duration of patients with intracranial tuberculous mass lesions.
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Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital and University of KwaZulu-Natal, Durban, 4091, South Africa
- Division of Neurology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, 7925, South Africa
| | - Ronald Van Toorn
- Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, 7505, South Africa
| | - Felicia C. Chow
- Weill Institute of Neurosciences and Department of Neurology and Division of Infectious Diseases, University of California, San Francisco, California, 94110, USA
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, 632004, India
| | - Omar K. Siddiqi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, 02215, USA
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Johan F. Schoeman
- Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, 7505, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, 7925, South Africa
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Marais S, Van Toorn R, Chow FC, Manesh A, Siddiqi OK, Figaji A, Schoeman JF, Meintjes G. Management of intracranial tuberculous mass lesions: how long should we treat for? Wellcome Open Res 2019; 4:158. [PMID: 32047859 PMCID: PMC6996525 DOI: 10.12688/wellcomeopenres.15501.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2019] [Indexed: 12/15/2022] Open
Abstract
Tuberculous intracranial mass lesions are common in settings with high tuberculosis (TB) incidence and HIV prevalence. The diagnosis of such lesions, which include tuberculoma and tuberculous abscesses, is often presumptive and based on radiological features, supportive evidence of TB elsewhere and response to TB treatment. However, the treatment response is unpredictable, with lesions frequently enlarging paradoxically or persisting for many years despite appropriate TB treatment and corticosteroid therapy. Most international guidelines recommend a 9-12 month course of TB treatment for central nervous system TB when the infecting Mycobacterium tuberculosis ( M.tb) strain is sensitive to first-line drugs. However, there is variation in opinion and practice with respect to the duration of TB treatment in patients with tuberculomas or tuberculous abscesses. A major reason for this is the lack of prospective clinical trial evidence. Some experts suggest continuing treatment until radiological resolution of enhancing lesions has been achieved, but this may unnecessarily expose patients to prolonged periods of potentially toxic drugs. It is currently unknown whether persistent radiological enhancement of intracranial tuberculomas after 9-12 months of treatment represents active disease, inflammatory response in a sterilized lesion or merely revascularization. The consequences of stopping TB treatment prior to resolution of lesional enhancement have rarely been explored. These important issues were discussed at the 3 rd International Tuberculous Meningitis Consortium meeting. Most clinicians were of the opinion that continued enhancement does not necessarily represent treatment failure and that prolonged TB therapy was not warranted in patients presumably infected with M.tb strains susceptible to first-line drugs. In this manuscript we highlight current medical treatment practices, benefits and disadvantages of different TB treatment durations and the need for evidence-based guidelines regarding the treatment duration of patients with intracranial tuberculous mass lesions.
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Affiliation(s)
- Suzaan Marais
- Department of Neurology, Inkosi Albert Luthuli Central Hospital and University of KwaZulu-Natal, Durban, 4091, South Africa
- Division of Neurology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, 7925, South Africa
| | - Ronald Van Toorn
- Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, 7505, South Africa
| | - Felicia C. Chow
- Weill Institute of Neurosciences and Department of Neurology and Division of Infectious Diseases, University of California, San Francisco, California, 94110, USA
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, 632004, India
| | - Omar K. Siddiqi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, 02215, USA
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience institute, University of Cape Town, Cape Town, 7700, South Africa
| | - Johan F. Schoeman
- Department of Pediatrics and Child Health, Stellenbosch University, Cape Town, 7505, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, 7925, South Africa
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Corticosteroid-dependent tuberculous meningitis: A case report. J Neurol Sci 2018; 396:232-234. [PMID: 30522040 DOI: 10.1016/j.jns.2018.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/22/2018] [Accepted: 11/16/2018] [Indexed: 11/20/2022]
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