ABSTRACT
La respuesta paradojal al tratamiento tuberculoso es la aparición de manifestaciones clínico-radiológicas nuevas, o el empeoramiento de las previas, luego de una mejoría inicial con el tratamiento específico. Se puede observar en 6-30% de los casos de tuberculosis meníngea. Es una reacción inmunológica exagerada y debe tenerse presente ya que su tratamiento se basa en el uso de inmunomoduladores y no en el cambio de las drogas antituberculosas. Presentamos el caso de una paciente adulta HIV negativa con meningitis tuberculosa que, luego de una adecuada respuesta inicial al tratamiento, intercurre a las 10 semanas con una reacción paradojal tratada satisfactoriamente con corticoides.
The paradoxical response to tuberculosis treatment consists in the appearance of new clinical or radiologic manifestations or worsening of previous injuries after an initial improvement with anti-tuberculosis therapy. It can be observed in 6 to 30 percent of the cases of tubercular meningitis. It is the consequence of an exaggerated immune reaction that should be considered since the treatment is based on the use of immunomodulators and not in the change of anti-tuberculous drugs. We present the case of an HIV negative adult with tuberculous meningitis with a good initial response to specific therapy who showed, 10 weeks later, a paradoxical reaction to treatment that responded successfully to corticosteroids.
Subject(s)
Humans , Female , Adolescent , Tuberculosis, Meningeal/diagnosis , Tuberculosis, Meningeal/drug therapy , Antitubercular Agents/therapeutic use , Tuberculosis, Meningeal/immunology , Treatment OutcomeABSTRACT
Lymphadenitis tuberculosis is the most frequent form of non pulmonary tuberculosis. Its incidence has increased in the last years probably because HIV co-infection. Usually manifests like a swelling of lymph nodes in the cervical region without constitutional symptoms. Diagnostics tests yields are poorer than in pulmonary tuberculosis probably due to the scarce bacillus population. Treatment is the same of pulmonary tuberculosis, but paradoxical reactions are far more frequent. These reactions, specially the latest presentations ones very often are treated as recurrence of the disease. Although this is always a possibility, in most cases they are due to an hypersensitivity reaction. In this article we present an illustrative case, an update on tuberculosis lymphadenitis and a review of the paradoxical reactions during its treatment.
La tuberculosis ganglionar es la forma más frecuente de tuberculosis extrapulmonar. Su incidencia ha aumentado, probablemente por la co-infección con VIH. Su presentación clínica más habitual es con un aumento de volumen de los ganglios cervicales sin síntomas constitucionales. Las pruebas diagnósticas tienen menos rendimiento que en la tuberculosis pulmonar por ser una enfermedad con menor población bacilar. Para el tratamiento se utilizan las mismas drogas y duración que en tuberculosis pulmonar, pero existe mayor incidencia de reacciones paradojales, las que pueden ser de difícil manejo. En este artículo presentamos primero un caso clínico particularmente ilustrativo, seguido de una puesta al día sobre tuberculosis ganglionar, incluyendo una revisión sobre el manejo de sus reacciones paradójicas.
Subject(s)
Humans , Female , Adult , Tuberculosis, Lymph Node/complications , Tuberculosis, Lymph Node/drug therapy , Antitubercular Agents/adverse effectsABSTRACT
La afectación del sistema nervioso central es una de las localizaciones extrapulmonares de la tuberculosis con peor pronóstico. El retraso en el diagnóstico y tratamiento es uno de los factores relacionados con mayor tasa de mortalidad y secuelas. Se describe la "reacción paradojal" como un deterioro sintomático de grado variable, durante el tratamiento efectivo de la tuberculosis. El aumento de la resistencia del Mycobacterium tuberculosis a fármacos observado en los últimos años genera mayor preocupación ante la aparición de una reacción paradojal durante el tratamiento. Se presenta el caso de un niño con meningitis tuberculosa que, luego de un mes de tratamiento, presentó empeoramiento clínico y nuevas lesiones en la tomografía y resonancia magnética nuclear de cerebro. Se excluyeron patologías asociadas, se verificó que la toma de medicamentos haya sido supervisada, y la sensibilidad del bacilo a fármacos antituberculosos de primera línea fue confirmada. El paciente no requirió cambios en el esquema de tratamiento antituberculoso y se administraron esteroides para el alivio sintomático. La reacción paradojal durante el tratamiento antituberculoso es infrecuente y debida a una reacción de hipersensibilidad entre el huésped y el bacilo tuberculoso. Cuando aparece, se debe asegurar la efectividad y el cumplimiento del tratamiento administrado.
The central nervous system is one of the locations of extrapulmonary tuberculosis with worse prognosis. The delay in diagnosis and treatment is one of the factors associated with higher mortality and sequelae. The "paradoxical reaction" is described as a variable degree of symptomatic deterioration during the effective treatment of tuberculosis. The increased resistance of Mycobacterium tuberculosis to drugs observed in recent years generates greater concern about the emergence of a paradoxical reaction during treatment. The case of a child with tuberculous meningitis that after one month of treatment presented clinical worsening and new lesions in CT and MRI images of the brain is presented. Comorbidities were excluded, it was verified that taking drugs has been monitored, and the sensitivity of the bacillus to first-line antituberculosis drugs was confirmed. The patient required no change in the pattern of tuberculosis treatment and steroids were administered for symptomatic relief. The paradoxical reaction during antituberculosis treatment is rare and due to a hypersensitivity reaction between the host and the tuberculous bacillus. When it appears you must ensure the effectiveness and compliance of the treatment.
Subject(s)
Humans , Child , Tuberculosis, Meningeal , Child , Tuberculosis, Central Nervous SystemABSTRACT
Tuberculosis is an important public health problem. It is estimated that around 5-10% of patients with tuberculosis present with central nervous system involvement; meningitis and tuberculoma being two of the most frequent manifestations. The paradoxical reaction in patients undergoing antituberculosis treatment is infrequent, nevertheless it is an important consideration in patients, who after an appropriate initial response to specific treatment, present with worsening clinical and radiological signs or the appearance of new lesions.
La tuberculosis (TBC) es un problema de importancia en salud pública. Se estima que alrededor de 5 a 10% de los pacientes con TBC presentan compromiso de sistema nervioso central, siendo la meningitis y el tuberculoma las manifestaciones más frecuentes. La reacción paradojal en pacientes con tratamiento antituberculoso es infrecuente, sin embargo, es importante considerarla en pacientes que durante la terapia, luego de una respuesta inicial apropiada, presentan un empeoramiento clínico y/o radiológico o aparición de nuevas lesiones.
Subject(s)
Adolescent , Female , Humans , Antitubercular Agents/adverse effects , Tuberculosis, Meningeal/drug therapy , Tuberculosis, Pulmonary/drug therapy , Adrenal Cortex Hormones/therapeutic use , Antitubercular Agents/therapeutic use , Immunocompetence , Magnetic Resonance Imaging , Tuberculoma, Intracranial/drug therapy , Tuberculosis, Meningeal/diagnosis , Tuberculosis, Pulmonary/diagnosisABSTRACT
The homeopathic model applies the secondary action or vital reaction of the organism as a therapeutic method and thus prescribes treatment by similitude, which consists in administering to ill individuals substances that cause similar symptoms in healthy individuals. The vital, homeostatic or paradoxical reaction of the organism might be explained scientifically by means of the rebound effect of modern drugs, which might cause fatal iatrogenic events after discontinuation of antipathic (a term used in alternative medicine for palliative treatment, also known as enantiopathic) treatment. Although the rebound effect is studied by modern pharmacology, it is poorly communicated to and discussed among healthcare professionals, who are thus deprived of information needed for the safe management of modern drugs. This article presents an up-to-date review on the rebound effect of modern drugs that grounds the homeopathic principle of healing and calls the attention of doctors to this type of adverse effect that is usually unnoticed. The rebound effect of modern palliative drugs, which was pointed out by Hahnemann more than two centuries ago, might cause fatal adverse events and is illustrated by the examples of acetylsalicylic acid, anti-inflammatory agents, bronchodilators, antidepressants, statins, proton-pump inhibitors, etc. Although the rebound effect is expressed by a small fraction of (susceptible) individuals and might be avoided by gradual tapering of antipathic drugs, it exhibits epidemiologic importance as a function of the massive use of such palliative drugs and the lack of knowledge in its regard.
O modelo homeopático aplica a ação secundária ou reação vital do organismo como método terapêutico. Assim, propõe o tratamento por semelhança, que consiste em administrar aos doentes substâncias que produzem sintomas similares em pessoas sadias. A reação vital, homeostática ou paradoxal do organismo pode ser explicada cientificamente com base no efeito rebote das drogas modernas. Este pode produzir eventos iatrogênicos fatais depois da suspensão do tratamento antipático (ou enantiopático, termo utilizado em medicina alternativa para se referir ao tratamento paliativo). Embora o efeito rebote é abordado pela farmacologia moderna, é pouco difundido e discutido pelos profissionais da saúde que, assim, são privados de informação necessária para o manejo seguro das drogas modernas. Este artigo apresenta uma revisão atualizada do efeito rebote das drogas modernas e que também embasa o princípio homeopático da cura. Apontado por Hahnemann mais de dois séculos atrás, o efeito rebote das drogas paliativas modernas pode causar efeitos adversos fatais, como ilustram os exemplos do ácido salicílico, anti-inflamatórios, broncodilatadores, antidepressivos, estatinas, inibidores da bomba de prótons, etc. Embora o efeito rebote seja expressado por uma pequena parte de indivíduos (suscetíveis) e possa ser evitando através da retirada gradual das drogas antipáticas, atinge importância epidemiológica devido ao uso maciço dessas drogas e do desconhecimento a seu respeito.