Highlights
- •Paradoxical deterioration occurred in 25% (3/12) of our patients with TB meningitis.
- •In 2 patients this was successfully managed with high dose corticosteroids alone.
- •1 patient deteriorated in spite of corticosteroids and cyclosporine was used.
- •Cyclosporine has a T cell suppressive effect, which may explain its efficacy.
Abstract
Background
Tuberculous meningitis (TBM) accounts for 1–4% of all tuberculosis (TB) presentations.
Paradoxical deterioration in non-HIV patients is a common manifestation of anti-tuberculosis
therapy, characterised by clinico-radiological deterioration. We report a case series
of TBM admissions to our institution including one case with paradoxical deterioration
refractory to corticosteroids who responded to adjuvant cyclosporine.
Methods
Retrospective review of 12 HIV-negative patients admitted to Liverpool Hospital, Sydney
(2005–2016) with laboratory and/or radiologically confirmed TBM.
Results
Median patient age was 40 (range 22–81 years), M:F = 7:5. Eleven patients (92%) were
of Asia-Pacific origin. Eleven initially presented with central nervous system manifestations
and one had preceding miliary TB. Nine patients had extra-cranial TB involvement including
eight with past or current pulmonary disease. Cerebrospinal fluid (CSF) TB PCR/culture
was positive in 10 patients. Paradoxical deterioration developed in three patients
despite concomitant corticosteroids in two. One patient with paradoxical deterioration
was refractory to corticosteroids: A 22-year-old Vietnamese male with TBM developed
worsening headaches and altered mentation after seven weeks concomitant anti-TB and
corticosteroid treatment. Interval MRI brain demonstrated increased size and number
of tuberculomas as well as hydrocephalus. Cyclosporine was added with gradual improvement
and ultimately good outcome.
Conclusion
Our case series highlights the seriousness of paradoxical deterioration in TBM and
the potential role of adjuvant cyclosporine in patients refractory to corticosteroids.
Keywords
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Article info
Publication history
Published online: July 13, 2019
Accepted:
July 8,
2019
Received in revised form:
June 9,
2019
Received:
June 10,
2018
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
