Korean J Gastroenterol.  2015 May;65(5):306-311. 10.4166/kjg.2015.65.5.306.

A Case of Paradoxical Reaction Development during Antituberculosis Therapy

Affiliations
  • 1Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Korea. medsgs@wonkwang.ac.kr

Abstract

Paradoxical reaction during antituberculosis therapy is defined as aggravation of preexisting tuberculous lesions or the development of new lesions. A 24-year-old female college student diagnosed with abdominal and pulmonary tuberculosis presented with fever and abdominal pain after having been treated with antituberculosis agents for 4 months. Tuberculous mesenteric lymphadenitis was suspected on abdominal CT scan and enlarged necrotic abscess was also present. These findings were considered to be due to paradoxical reaction rather than treatment failure during antituberculosis treatment. Although laparoscopic bowel adhesiolysis and abscess drainage were performed, high fever and severe abdominal pain did not improve. However, the patient eventually made a completely recovery after corticosteroid therapy combined with antituberculosis agents. Herein, we report a case of paradoxical reaction which developed in a patient with abdominal and pulmonary tuberculosis during antituberculosis therapy.

Keyword

Paradoxical reaction; Peritonitis, tuberculous; Tuberculosis, pulmonary; Corticosteroid

MeSH Terms

Abscess
Adrenal Cortex Hormones/therapeutic use
Antitubercular Agents/*therapeutic use
Drainage
Female
Humans
Mesenteric Lymphadenitis/etiology
Tomography, X-Ray Computed
Tuberculosis/*drug therapy/pathology
Tuberculosis, Pulmonary/diagnosis/pathology
Young Adult
Adrenal Cortex Hormones
Antitubercular Agents

Figure

  • Fig. 1. Chest CT findings. (A) Chest CT shows ill-defined patchy consolidation and small nodules in the right upper lobe. (B) Four months after initiation of antituberculosis therapy, previous lesion is markedly reduced.

  • Fig. 2. Abdominal CT findings. (A) About 1-cm sized lymphadenopathy with multiple lymphadenopathies is noted on the ileocecal area (arrow).(B) Four months after initiation of antituberculosis treatment, about 4-cm sized conglomerated lymph node with central necrosis is detected on the ileocecal area (arrow). (C) One month after laparoscopic drainage and adjuctive corticosteroid therapy, the conglomerated mass is reduced (arrow). (D) One year after laparoscopic drainage and adjuctive corticosteroid treatment, the previous lesion is decreased to normal range.

  • Fig. 3. Colonoscopic and microscopic findings. (A) Exudate covered shallow ulcer is shown on terminal ileum. (B) Presence of chronic granuloma with epithelioid cells (arrows) is compatible with intestinal tuberculosis (H&E stain, ×200).

  • Fig. 4. Histological finding of peritoneal wall. Peritoneal biopsy shows chronic granulomatous inflammation with epithelioid cell (arrows) and necrosis (asterisk), consistent with tuberculous peritonitis (H&E stain, ×200).


Reference

References

1. Cheng VC, Ho PL, Lee RA, et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-in-fected patients. Eur J Clin Microbiol Infect Dis. 2002; 21:803–809.
Article
2. Al-Majed SA. Study of paradoxical response to chemotherapy in tuberculous pleural effusion. Respir Med. 1996; 90:211–214.
Article
3. Hawkey CR, Yap T, Pereira J, et al. Characterization and management of paradoxical upgrading reactions in HIV-uninfected patients with lymph node tuberculosis. Clin Infect Dis. 2005; 40:1368–1371.
Article
4. Cheng VC, Yam WC, Woo PC, et al. Risk factors for development of paradoxical response during antituberculosis therapy in HIV-negative patients. Eur J Clin Microbiol Infect Dis. 2003; 22:597–602.
Article
5. Carvalho AC, De Iaco G, Saleri N, et al. Paradoxical reaction during tuberculosis treatment in HIV-seronegative patients. Clin Infect Dis. 2006; 42:893–895.
Article
6. Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med. 2003; 167:603–662.
7. Ahn TH, Park MB, Lee KJ, et al. A case report of tuberculous brain abscess and tuberculous peritonitis developing due to paradoxical reactions. Tuberc Respir Dis. 2009; 66:457–462.
Article
8. Kasahara K, Fukuoka A, Murakawa K, et al. Tuberculous peritonitis developing during chemotherapy for pulmonary and intestinal tuberculosis: a case report. Respirology. 2005; 10:257–260.
Article
9. Kim SY, Oh TH, Seo JY, et al. A case of tuberculous peritonitis developed during chemotherapy for tuberculous pleurisy as paradoxical response. Korean J Gastroenterol. 2011; 57:379–383.
Article
10. Bukharie H. Paradoxical response to antituberculous drugs: resolution with corticosteroid therapy. Scand J Infect Dis. 2000; 32:96–97.
Article
11. Lee YJ, Jung SH, Hyun WJ, et al. A case of obstructive jaundice caused by paradoxical reaction during antituberculous chemotherapy for abdominal tuberculosis. Gut Liver. 2009; 3:338–342.
Article
12. Dixit R, Nuwal P, Arya M. Splenic abscess as a paradoxical response to chemotherapy in tuberculous pleural effusion. Ann Thorac Med. 2010; 5:50–51.
Article
13. Kim YS, Kim YH, Lee KM, Kim JS, Park YS. IBD Study Group of the Korean Association of the Study of Intestinal Diseases. Diagnostic guideline of intestinal tuberculosis. Korean J Gastroenterol. 2009; 53:177–186.
14. Geri G, Passeron A, Heym B, et al. Paradoxical reactions during treatment of tuberculosis with extrapulmonary manifestations in HIV-negative patients. Infection. 2013; 41:537–543.
Article
15. Kim SH, Chung HY, Lee GD, et al. Clinical characteristics of paradoxical response to chemotherapy in pulmonary tuberculosis. Tuberc Respir Dis. 2002; 53:27–35.
Article
16. Grange JM, Stanford JL, Rook GA. Tuberculosis and cancer: par-allels in host responses and therapeutic approaches? Lancet. 1995; 345:1350–1352.
Article
17. Garcia Vidal C, Garau J. Systemic steroid treatment of paradoxical upgrading reaction in patients with lymph node tuberculosis. Clin Infect Dis. 2005; 41:915–916.
18. Garcia Vidal C, Rodríguez Fernández S, Martínez Lacasa J, et al. Paradoxical response to antituberculous therapy in infliximab- treated patients with disseminated tuberculosis. Clin Infect Dis. 2005; 40:756–759.
19. Wendel KA, Alwood KS, Gachuhi R, Chaisson RE, Bishai WR, Sterling TR. Paradoxical worsening of tuberculosis in HIV-in-fected persons. Chest. 2001; 120:193–197.
Article
20. Cho OH, Park KH, Kim T, et al. Paradoxical responses in non-HIV-infected patients with peripheral lymph node tuberculosis. J Infect. 2009; 59:56–61.
Article
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