Paradoxical upgradation response in non-HIV tuberculosis: Report of two cases

A paradoxical upgradation response in tuberculosis (TB) is defined as the worsening of a pre-existing tubercular lesion or the appearance of a new lesion in a patient whose clinical symptoms initially improved with anti-TB treatment. A paradoxical response is common in HIV patients in the form of immune reconstitution inflammatory syndrome. A similar kind of response can also be seen in immunocompetent patients. Here, we present two cases of non-HIV TB who initially improved with antitubercular therapy (ATT) but worsened thereafter. After excluding possibilities such as multidrug-resistant TB, treatment failure or a superadded infection, a paradoxical upgradation response was diagnosed. Both the cases improved after treatment with corticosteroids in addition to ATT.

Paradoxical response as a cervical lymph node enlargement after termination of anti-tuberculosis treatment in a patient with pulmonary tuberculosis / 고신대학교의과대학학술지

A paradoxical response is not uncommon in non-HIV-infected patients, particularly those with extra-pulmonary tuberculosis. It is defined as the radiological and clinical worsening of a previous lesion or the development of new lesion during anti-tuberculosis therapy. The paradoxical response has been attributed to host immunologic reactions, such as a delayed hypersensitivity or a response to mycobacterial antigens. In most reports of paradoxical response, these responses occurred in the same location as a previous lesion. In this patient with pulmonary tuberculosis, cervical lymph node enlargement occurred as a paradoxical response after the completion of anti-tuberculosis treatment. Although the new lesion developed in another location, it could be considered as a paradoxical response based on the negative culture result of acid fast bacilli from the new lesion and drug sensitivity result from initial bronchoalveolar lavage specimen. Therefore we were able to decide on the termination of unnecessary anti-tuberculous treatment. Based on our case, we can conclude that paradoxical response can occur after the termination of anti-tuberculosis therapy even in new site.

Paralysis Developing as a Paradoxical Response During the Treatment for Tuberculous Spondylitis: A Case Report

It can be difficult for clinicians to distinguish a paradoxical response to antituberculous therapy, worsening of an existing lesion despite adequate treatment, treatment failure, and drug resistance. We report a case of a 69-year-old woman who experienced bilateral lower extremity paralysis secondary to a paradoxical response. She had been suffering for 1 month from low back pain, due to tuberculous spondylitis. Her low back pain improved after antituberculous therapy. The low back pain, however, reappeared 2 months after treatment, accompanied by newly developed lower extremity weakness. Imaging studies showed an increased extent of her previous lesions. Consequently, the patient underwent a vertebral corpectomy with interbody fusion of the thoracolumbar spine. Histopathological examination showed chronic inflamed granulation tissue with no microorganisms. Although the antituberculous medication was not changed, the patient's symptoms and signs, including the paralysis, resolved after surgery.

Tuberculous Iliopsoas Muscle Abscess Associated with Multiple Intraabdominal and Thoracic Abscesses in 9-year-old Boy

Tuberculous Iliopsoas muscle abscess is a rare manifestation in patient with extrapulmonary tuberculosis and hardly observed in developed country. Paradoxical response to anti-tuberculous medication could make difficult therapeutic decision to clinicians. The authors report a case of tuberculous iliopsoas muscle abscess with multiple intraabdominal and thoracic abscesses in 9 year-old-boy who presented paradoxical response to anti-tuberculous treatment.

A Case of Tuberculous Liver Abscess Developed during Chemotherapy for Tuberculous Peritonitis as Paradoxical Response / 대한소화기학회지

Tuberculous liver abscesses are rare. Paradoxical response in tuberculosis is common and occurred between 2 weeks and 12 weeks after anti-tuberculous medication. We report here a case of tuberculous liver abscess that developed in a paradoxical response during chemotherapy for tuberculous peritonitis in a 23-year-old male. He was hospitalized, complaining of ascites, epigastric pain. He was diagnosed tuberculous peritonitis by expiratory laparoscopic biopsy and took medication for tuberculosis. After 2 months, a hepatic lesion was detected with CT scan incidentally. Chronic granulomatous inflammation was seen in ultrasound-guided liver biopsy, and tuberculous liver abscess was diasnosed. It was considered as paradoxical response, rather than treatment failure or other else because clinical symptoms of peritoneal tuberculosis and CT scan improved. After continuing initial anti-tuberculous medication, he was successfully treated. Herein, we report a case of tuberculous liver abscess as paradoxical response while treating peritoneal tuberculosis without changing anti-tuberculous treatment regimen.

Development of a Tuberculous Liver Abscess as a Paradoxical Response / 대한내과학회지

Tuberculous liver abscesses are rare. We report here a case of tuberculous liver abscess that developed in a paradoxical response during appropriate anti-tuberculosis chemotherapy in a 50-year-old male. In this case, a paradoxical response to the treatment of intestinal tuberculosis may have been involved in the pathogenesis of the liver abscess.

A Case of Tuberculous Peritonitis Developed during Chemotherapy for Tuberculous Pleurisy as Paradoxical Response / 대한소화기학회지

After the start of anti-tuberculous treatment, paradoxical worsening of tuberculous lesions has been described. However, abdominal tuberculosis as paradoxical response is relatively rare. This report describes the 26-year-old female who suffered from peritoneal tuberculosis while treating tuberculous pleurisy with anti-tuberculous medications. It was considered as paradoxical response, rather than treatment failure or else. She was successfully managed with continuing initial anti-tuberculous medications. When a patient on anti-tuberculous medications is presented with abdominal symptoms, the possibility of paradoxical response should be considered to avoid unnecessary tests and treatments, which may result in more suffering of the patient. Herein, we report a case of peritoneal tuberculosis as paradoxical response while treating tuberculous pleurisy.

A Case Report of Tuberculous Brain Abscess and Tuberculous Peritonitis Developing Due to Paradoxical Reactions / 결핵및호흡기질환

While receiving appropriate treatment, patients with tuberculosis occasionally have unusual, paradoxical reactions, with transient worsening of lesions or the development of new lesions. This report is a case of tuberculosis brain abscess and tuberculosis peritonitis with intra-abdominal abscess that developed during appropriate anti-tuberculosis chemotherapy. A 45-year-old male patient had been diagnosed as with all-drug susceptible pulmonary tuberculosis with pleurisy. Subsequently, the patient underwent standard treatment with anti-tuberculosis therapy; the pulmonary lesions improved. Three months after initial treatment, the patient developed brain abscesses and peritonitis. With the addition of corticosteroid treatment, the patient's neurologic symptoms were relieved. Exploratory laparotomy with surgical drainage was performed and a diagnosis of tuberculosis peritonitis was confirmed on biopsy. Anti-tuberculosis therapy was continued for 19 months, the patient improved eventually without further complications, although the therapeutic regimen had not been altered. In this case, the paradoxical response to treatment may have been involved in the pathogenesis of disease.

A case of newly developed pulmonary lesion during the antitubercular agents in tuberculous pleurisy : A paradoxical response / 소아과

Paradoxical response refers to the enlargement of old lesions or unexpected appearance of new lesions after initial improvement following treatment with antitubercular agents. Various types of paradoxical responses have been reported in the world, but they are rarely reported in Korean children. We report the case of a 17-year-old boy who was diagnosed with tuberculous pleurisy and was treated appropriately. Although the tuberculous pleurisy initially responded to medication with resolution of the pleural fluid, a new pulmonary lesion subsequently developed 3 weeks after the initiation of treatment that eventually cleared with continuation of the original drug regimen.

A Case of Different Response of Miliary Lung and Intracranial Nodules to Antituberculous Therapy / 결핵및호흡기질환

Although a paradoxical response of tuberculosis to antituberculous therapy is not a rare phenomenon, it can be a clinical challenge to differentiate a paradoxical response from treatment failure. A 25-year-old woman was admitted for miliary lung nodules and multiple intracranial nodules. Antituberculous treatment was started with a preliminary diagnosis of tuberculosis based on the history and clinical findings. After one month, the miliary lung nodules improved while the intracranial nodules increased in size and number. Based on a stereotactic biopsy, it was confirmed that the intracranial lesions were tuberculomas. Although the therapeutic regimen was not changed, the symptoms eventually were ameliorated and the intracranial nodules improved two months later.

Paradoxical Response Developed during the Antituberculous Treatment in Tuberculous Pleurisy / 결핵및호흡기질환

BACKGROUND: A paradoxical response is defined as the radiological and clinical worsening of a previous lesion or the development of new lesion after initial improvement during theprocess of antituberculous treatment. The related factors for the development of a paradoxical response in patients with tuberculous pleurisy are not certain. METHODS: We selected patients with tuberculous pleurisy who had been treated for more than 4 months. The changes onthe serial chest X-ray findings before and after treatment were reviewed. Paradoxical responses were regarded as any worsening or development of new lesion at least 2 weeks after the initiation of treatment. The baseline clinical characteristics and laboratory findings of the peripheral blood and pleural fluid were compared between the patients with a paradoxical response and the patients without a paradoxical response. RESULTS: Paradoxical responses appeared in sixteen patients (21%) among the 77 patients.It took a mean of 38.6 days after the treatment and the time to resolve the paradoxical response was a mean of 32.1 days. For the patients with a paradoxical response, the median age was younger (30.5 years vs 39.0 years, respectively) and the lymphocytic percentage of white blood cells in the pleural fluid was higher (82.1% vs 69.6%, respectively) than for the patients without a paradoxical response. CONCLUSION: The development of a paradoxical response during the treatment of patients with tuberculous pleurisy was not rare and this was related with the age of the patients and the percentage of lymphocytic white blood cells in the pleural fluid.

The CT findings and clinical course of intraperitoneal tuberculous abscess / 대한내과학회지

Paradoxical response during antituberculosis treatment occurs frequently in non-HIV-infected patients as well as in HIV-infected patients, and intraperitoneal tuberculous abscess can develop as paradoxical response in tuberculous peritonitis patients rarely. The unique CT findings are not present and microbiologic or pathologic confirm is needed for diagnosis of intraperitoneal tuberculous abscess. Further study is needed to define steroid use or operation indication of intraperitoneal tuberculosis abscess.

Acute Respiratory Distress Syndrome as a paradoxical response to anti-tuberculosis and anti-retroviral therapy.

Paradoxical response or immune reconstitution inflammatory syndrome (IRIS) during the course of antituberculous therapy is being increasingly recognised among patients with and without HIV co-infection. A 40-year-old HIV infected male on anti-retroviral therapy (ART) presented with persistent fever and weight loss. He was diagnosed to have miliary tuberculosis and HIV co-infection. Following initiation of anti-tuberculous chemotherapy, the clinical course was characterised by development of acute respiratory failure (ARDS) as a paradoxical response/IRIS to treatment. This uncommon manifestation of paradoxical response (ARDS) in HIV and tuberculous co-infection following initiation of ART and anti-TB treatment is very scarcely reported in the past. With the increasing incidence of HIV/AIDS and TB co-infection along with liberal access to ART in the developing world, it is likely that paradoxical reactions will be encountered more frequently.

Clinical Characteristics of Paradoxical Response to Chemotherapy in Pulmonary Tuberculosis / 결핵

BACKGROUND: The paradoxical response refers to an enlargement of old lesions or unexpected new ones during apparently adequate antituberculous therapy. This response has been reported in cases of intracranial tuberculoma, tuberculous lymphadenopathy, tuberculous pleurisy and pulmonary tuberculosis. However, there are few reports on its frequency and clinical characteristics. METHOD: This study enrolled 205 patients who were treated with first line antituberculous agents for more than 6 months. We retrospectively studied 155 patients with pulmonary tuberculosis and 57 patients with pleural tuberculosis (7 patients had both) from July 1998 to March 2000. The patients were divided into the paradoxical response group and the non-paradoxical group. The clinical characteristics of the paradoxical group were investigated. Statistical analysis was done with an independent sample T-test and Chi-squared test. RESULT: 29 of the 205 patients(14.1%) had paradoxical response. Among the 29 patients, there were 19 pulmonary tuberculosis, 8 tuberculous pleurisy(2 patients had both). Paradoxical response appeared 32 days (mean 35 days in pulmonary tuberculosis, mean 25 days in tuberculous pleurisy) after the beginning of chemotherapy. The duration to regress less than half of initial chest lesion was 114 days in pulmonary tuberculosis and 124 days in tuberculous pleurisy, respectively. Most common clinical manifestation of paradoxical response patients was coughing in both pulmonary tuberculosis and tuberculous pleurisy. Male sex, high blood WBC count and high level of pleural fluid LDH were related with paradoxical response. CONCLUSION: These findings suggest that presponse usually appears 1 month and disappears within 4 months after the beginning of anti-tuberculous chemotherapy. Paradoxical response was relatively correlated with male sex, high blood WBC count and high level of pleural fluid LDH.