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Review
. 2020 Oct 23;99(43):e22626.
doi: 10.1097/MD.0000000000022626.

Tumor necrosis factor antagonists for paradoxical inflammatory reactions in the central nervous system tuberculosis: Case report and review

Miguel Santin  1   2 , Cristina Escrich  3 , Carles Majòs  4 , Mariona Llaberia  5 , Maria D Grijota  1 , Imma Grau  2   5
Affiliations
Review

Tumor necrosis factor antagonists for paradoxical inflammatory reactions in the central nervous system tuberculosis: Case report and review

Miguel Santin et al. Medicine (Baltimore). .

Abstract

Rationale: Paradoxical reaction/immune reconstitution inflammatory syndrome is common in patients with central nervous system tuberculosis. Management relies on high-dose corticosteroids and surgery when feasible.

Patient concern: We describe 2 cases of HIV-negative patients with corticosteroid-refractory paradoxical reactions of central nervous system tuberculosis.

Diagnoses: The 2 patients experienced clinical impairment shortly after starting therapy for TB, and magnetic resonance imaging showed the presence of tuberculomas, leading to the diagnosis of a paradoxical reaction.

Interventions: We added infliximab, an anti-tumor necrosis factor (TNF)-alpha monoclonal antibody, to the dexamethasone.

Outcomes: Both patients had favorable outcomes, 1 achieving full recovery but 1 suffering neurologic sequelae.

Lessons: Clinicians should be aware of the risk of paradoxical reactions/immune reconstitution inflammatory syndrome when treating patients with tuberculosis of the central nervous system and should consider the prompt anti-TNF-α agents in cases not responding to corticosteroids.

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Conflict of interest statement

The authors do not have conflicts of interests to disclose.

Figures

Figure 1
Figure 1
Magnetic resonance imaging of case 1. Axial and sagittal fluid-attenuated inversion recovery images without gadolinium (A) and axial and coronal T1-weighted images with gadolinium (B) performed 5 (September 2015) and 8 weeks (October 2015) respectively after starting tuberculosis treatment, showing multiple supra-and infratentorial lesions, distributed in the brain parenchyma and subarachnoid space. Axial and sagittal scans without gadolinium (C), taken after 6 weeks after receiving a three-dose course of infliximab, showing complete resolution of the tuberculomas.
Figure 2
Figure 2
Axial and coronal contrast-enhanced T1-weighted magnetic resonance images of case 2. At diagnosis (September 2017): extraparenchymal enhancing lesion on the right ambient cistern infiltrating the right superior colliculus (A). Six weeks later (November 2017): appearance of new tuberculomas in midbrain tegmentum, suprasellar cisterns and right temporal uncus (B). After 3 weeks of a three-dose course of infliximab (February 2018): Remarkable reduction of tuberculomas and leptomeningeal enhancement (C). On the eleventh month of tuberculosis treatment (July 2018): obstructive hydrocephalus secondary to mass effect over Silvius aqueduct (D). And 3 months after discontinuation of tuberculosis treatment (December 2018): Mild leptomeningeal enhancement, with resolution of the mass effect (E).
Figure 3
Figure 3
Detailed axial (A) and coronal (B) contrast-enhanced T1-weighted magnetic resonance images showing enlargement of III ventricle and temporal lateral ventricle horns (arrows) due to obstructive hydrocephalus secondary to mass effect over Silvius aqueduct (arrowhead).
See this image and copyright information in PMC

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