SESSION TYPE: Infectious Disease Cases II
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Patients can develop clinical or radiological worsening of pre-existing tuberculous lesion or develop new lesions during anti- tuberculosis therapy (ATT). Such a paradoxical response is well reported in HIV patients. We report a case of paradoxical response in a non-HIV patient during therapy for pulmonary tuberculosis
CASE PRESENTATION: A 68 year old Vietnamese female presented with a 2 month history of low grade fever, night sweats, pleuritic chest pain, dry cough and progressive dyspnea. Past history included asthma, a positive tuberculin skin test since 2001. She denied exposure to active TB patients or contacts; no recent travel abroad. She emigrated to US (1996) and last visited Vietnam in 2007. On examination she is afebrile, with decreased air entry in right anterior chest. Her blood counts, metabolic panel and office spirometry were normal. HIV was negative. A computed Tomogram (CT) of chest showed a right upper lobe cavity with surrounding consolidation. A bronchoalveolar lavage (BAL) fluid showed neutrophilia (N 64%), smear negative for acid fast bacilli (AFB), fungi and malignant cells. She was treated for pulmonary tuberculosis due to high clinical probability pending cultures, which subsequently grew pan susceptible mycobacterium tuberculosis (MTB). she remained symptomatic (chest pain , dry cough) despite therapy. Repeat imaging at 1 and 2 month intervals showed new subpleural pulmonary nodules with resolution of the cavitary lesion. Multiple CT guided biopsies of these nodules showed pneumonitis and did not grow MTB A right lower lobe wedge resection inclusive of nodules confirmed granulomatous inflammation, fibrosis and organizing pneumonia with cytology and cultures negative for MTB. She was continued on ATT with a regimen change and clinically improved.
DISCUSSION: A diagnosis of paradoxical response warrants exclusion of secondary infection, treatment failure (drug resistance, poor compliance) and drug reaction. Paradoxical response has been reported more often in extra-pulmonary disease( CNS) with median onset time of 60 days. Risk factors include anemia, hypoalbuminemia, lymphopenia, greater % increase in lymphocyte count and a low body mass index (BMI) Our patient had low BMI (17.5) as a risk factor; all other causes of worsening infiltrates were excluded. A complete recovery was noted to occur in 78% of cases
CONCLUSIONS: A clinical or radiological worsening during Tb therapy occurs in 6-30 % cases.A Paradoxical response should be considered in the differential diagnosis of worsening infiltrates during TB therapy in HIV negative patients after excluding other causes.
1) Risk Factors for Paradoxical Response During Anti -Tuberculosis Therapy in HIV-Negative Patients. Cheng etal Eur J Clin Microbiol (2003) 22:597-602
2) Paradoxical response during anti-tuberculosis treatment in HIV-negative patients with pulmonary tuberculosis S-L. Cheng etal INT J TUBERC LUNG DIS 11(12):1290-1295 2007
DISCLOSURE: The following authors have nothing to disclose: Anand Kommuri, Nikhil Madan, Salvatore Mangione, Mani Kavuru
No Product/Research Disclosure InformationThomas Jefferson University Hospital, Philadelphia, PA