Paradoxical reactions during treatment of tuberculosis with extrapulmonary manifestations in HIV-negative patients

Tuberculous paradoxical reactions (PR) have been seldom studied in non-immunocompromised patients. We conducted a study to describe the incidence, clinical and biological features, treatment and outcome of PR in human immunodeficiency virus (HIV)-negative patients treated for extrapulmonary tuberculosis (TB) and to identify predictive factors of PR.

A single-center retrospective study was conducted in consecutive HIV-negative patients presenting with TB with at least one extrapulmonary manifestation who were hospitalized in an internal medicine department between 2000 and 2010.

Seventy-six patients were enrolled in the study. Lymphadenitis was the most common extrapulmonary manifestation of tuberculosis among this patient population (72 %). PR occurred in 19 (25 %) patients, mostly involving the lymph nodes (68 %) and lung (16 %), but also the pericardium, pleura, bone, muscle and brain. Median time to PR onset after initiation of anti-TB regimen was 86 days (interquartile range 36–125). Treatment of PR consisted mainly of corticosteroids (47 % of patients) and needle aspiration of PR lymph nodes (31 %). Peripheral lymph node involvement (p = 0.009), lymphopenia (p = 0.03) and anemia (p = 0.002) at presentation were associated with PR occurrence. Outcome was favorable in all patients with PR but one; the latter suffered residual paraplegia.

Paradoxical reactions are frequent in the course of extrapulmonary TB treatment in HIV-negative patients but their outcome is excellent, except in some cases with central nervous system involvement.