Recurrent paradoxical reactions as non-communicating hydrocephalus and basal meningitis in a non-HIV patient with tuberculous meningitis and tuberculoma

Background

Tuberculosis meningitisis the most devastating form of Tuberculosis, causing high mortality or disability. Paradoxical neuro-inflammatory reactions, which occur despite appropriate anti-TB chemotherapy, may reflect the host response to dead and dying bacterial.

Case report

We report a case involving paradoxical reaction, effectively managed with emergent external ventricular drainage (EVD). The patient, a healthy 30-year-old Burmese woman, was diagnosed with disseminated tuberculosis involving pulmonary disease, vertebral osteomyelitis, and meningitis. Treatment included isoniazid (INH) 300 mg/day, rifampicin (RFP) 450 mg/day, ethambutol (EB) 750 mg/day, pyrazinamide (PZA) 1250 mg/day, levofloxacin (LVFX) 500 mg/day, and Dexamethasone (DEX) 0.4 mg/kg/day. A week after treatment initiation, she experienced the a paradoxical reaction but found relief with symptomatic treatment. Due to susceptibility of tuberculosis, we transitioned her to INH+RFP+LVFX, and DEXA was discontinued after two months. On day 66, she was readmitted with worsening symptoms and was diagnosed with a second paradoxical reaction and hydrocephalus. Neurosurgery inserted an EVD tube and resumed DEXA. The patient showed significant improvement, and the EVD was subsequently removed. DEXA was stopped after 4 months.There was no recurrence in one year.

Conclusion

During the treatment of TBM, a paradoxical reaction can occur at any time. Therefore, we recommend the necessity of collaborating with a neurosurgeon to facilitate emergency EVD drainage for the management of hydrocephalus.