Severe paradoxical reaction in tuberculous meningitis

Abstract

A 31-year-old female presented with a 3-week history of fever and headache. CSF Ziehl-Neelsen smear microscopy revealed acid-fast bacilli, and CSF GeneXpert MTB/RIF was positive for Mycobacterium tuberculosis with no mutations of rifampicin resistance. Tuberculous meningitis (TBM) was diagnosed. Baseline contrast-enhanced brain magnetic resonance imaging (MRI) was unremarkable. Eight weeks later the patient developed markedly reduced visual acuity and clinical signs consistent with left 3rd and 6th cranial nerve palsies. Repeat contrast-enhanced brain MRI revealed extensive tuberculous exudate filling the basal cisterns of the brain consistent with a severe paradoxical reaction of TBM. High dose intravenous dexamethasone was administered, with visual acuity returning to near-normal over 3-4 weeks. In TBM paradoxical inflammatory reactions are common yet difficult to predict. When severe, they may result in substantial neurological morbidity and death. Prompt host directed therapies such as corticosteroids may reduce chances of permanent neurological damage.

Keywords: Paradoxical reaction; Tuberculous meningitis.

Fig. 1

Sagittal and axial contrast-enhanced MRI images of a 31-year-old woman with TBM, before (A & B) and at the time of (C & D) a severe paradoxical reaction. Baseline sagittal (A) and axial (B) images show no neuroinflammatory features of TBM. Repeat imaging after 2 months shows extensive tuberculous exudate filling the cisterna pontis (anterior to the pons), interpeduncular cistern (anterior and superior to the pons), and cisterna ambiens (superior to the cerebellum), of the brain (C & D). Sagittal imaging (C) shows clear delineation between exudate-filled cistern and surrounding brain structures. Axial imaging (D) demonstrates a thick exudative ring with anterior projections, typical of basal exudate appearances in TBM. MRI = Magnetic resonance imaging. TBM = Tuberculous meningitis.