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

• Published in: Medicine (Baltimore) Vol. 99; no. 43; p. e22626
• Main Authors: Santin, Miguel, Escrich, Cristina, Majòs, Carles, Llaberia, Mariona, Grijota, Maria D, Grau, Imma
• Format: Journal Article
• Language: English
• Published: United States Lippincott Williams & Wilkins 23.10.2020
• Subjects: Adult; Brain - diagnostic imaging; Brain - drug effects; Brain - immunology; Brain - pathology; Clinical Case Report; Female; Humans; Immune Reconstitution Inflammatory Syndrome - etiology; Immune Reconstitution Inflammatory Syndrome - pathology; Male; Middle Aged; Tuberculosis, Central Nervous System - complications; Tuberculosis, Central Nervous System - drug therapy; Tumor Necrosis Factor Inhibitors - therapeutic use; Young Adult
• ISSN: 0025-7974; 1536-5964
• DOI: 10.1097/MD.0000000000022626

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. We describe 2 cases of HIV-negative patients with corticosteroid-refractory paradoxical reactions of central nervous system tuberculosis. 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. We added infliximab, an anti-tumor necrosis factor (TNF)-alpha monoclonal antibody, to the dexamethasone. Both patients had favorable outcomes, 1 achieving full recovery but 1 suffering neurologic sequelae. 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.