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Tuberculosis of the Central Nervous System pp 485–498Cite as

Paradoxical Worsening of Tuberculosis of the Nervous System During Treatment

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Abstract

Paradoxical worsening of tuberculosis (TB) during treatment or paradoxical reactions (PRs) is defined as deterioration of pre-existing TB of the nervous system or appearance of new TB lesions on anti-TB treatment. It is much more common than previously thought and may be seen in more than 50% of patients with nervous system TB. PR is also seen in HIV patients after initiation of highly active anti-retroviral treatment and is referred to as paradoxical immune reconstitution inflammatory syndrome (IRIS). Acute worsening may occur secondary to worsening leptomeningeal exudates, increase in size of persisting tuberculoma or appearance of new tuberculoma, infarcts, or worsening of hydrocephalus. These features may occur at a variable period ranging from few days to several months after starting of treatment. The precise pathophysiology of PR is not known. It is believed that an exaggerated immune response to mycobacterial antigen is responsible for PR. A reduced CD4 cell count, a high retroviral load, and small time lag between initiation of anti-retroviral therapy and anti-TB treatment are predictors of paradoxical-IRIS. Majority of patients improve on continued anti-TB treatment and steroids. Other immunomodulators have also been used in individual patients not improving on corticosteroids. PR may produce life-threatening complications like hydrocephalus or increase in size of tuberculoma or TB abscess that may require urgent neurosurgical intervention. Permanent neurological sequelae may occur in patients like vision loss, hemiparesis or paraparesis, and permanent behavioral or cognitive deficits.

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Abbreviations

CNS:

Central nervous system

CSF:

Cerebrospinal fluid

HART:

Highly active anti-retroviral treatment

HIV:

Human immunodeficiency virus

IFN:

Interferon

IL:

Interleukins

IRIS:

Immune reconstitution inflammatory syndrome

PR:

Paradoxical reaction

PR-IRIS:

Paradoxical immune reconstitution inflammatory syndrome

TB:

Tuberculosis

TBM:

Tuberculous meningitis

TLR:

Toll-like receptors

TNF:

Tumor necrosis factor

TREM:

Triggering receptor expressed on myeloid cells

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Authors and Affiliations

  1. Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, 226014, India

    Vimal Kumar Paliwal

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  1. Vimal Kumar Paliwal
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Correspondence to Vimal Kumar Paliwal .

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Editors and Affiliations

  1. Adnan Menderes University, School of Medicine, Aydın, Turkey

    Mehmet Turgut

  2. Mohammed V University in Rabat, Avicenne Military Hospital of Marrakech, Rabat, Morocco

    Ali Akhaddar

  3. Hacettepe University, School of Medicine, Ankara, Turkey

    Ahmet T. Turgut

  4. King George Medical University, Lucknow, Uttar Pradesh, India

    Ravindra K. Garg

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Paliwal, V.K. (2017). Paradoxical Worsening of Tuberculosis of the Nervous System During Treatment. In: Turgut, M., Akhaddar, A., Turgut, A., Garg, R. (eds) Tuberculosis of the Central Nervous System. Springer, Cham. https://doi.org/10.1007/978-3-319-50712-5_34

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