Respuesta paradójica durante el tratamiento tuberculostático en pacientes inmunocompetentes

Tuberculosis‐immune reconstitution inflammatory syndrome in HIV ‐negative children

Even though tuberculosis‐immune reconstitution inflammatory syndrome (TB‐IRIS) is usually found in HIV‐positive patients receiving antiviral treatment, it can also occur in HIV‐negative patients especially if they have risk factors. We report a unique case of TB‐IRIS in an immunocompetent child presenting with new onset of pleuritic chest pain after receiving anti‐TB drugs. TB‐IRIS should be considered as a differential diagnosis in case of clinical deterioration or appearance of new typical lesions despite appropriate anti‐TB treatment for more than 2 weeks in the absence of persistently active TB or any other alternative causes. This will prevent physicians from misdiagnosis as superimposed infections, treatment failure or TB relapse.

Paradoxical reaction in immunocompetent children with tuberculosis

BACKGROUND

A paradoxical reaction (PR) during anti-tuberculosis treatment is a phenomenon that is poorly studied in immunocompetent children. It is defined as a clinical or radiological worsening of pre-existing tuberculosis (TB) disease.

METHODS

A retrospective descriptive study of children younger than 14 years of age was performed; these children developed PR during the years 2009 to 2014, following a diagnosis of TB. Demographic characteristics, microbiological results, treatment and outcome data were collected.

RESULTS

Of 51 children diagnosed with TB, five (9.8%) developed a PR; four of these children had pulmonary TB and the remaining patient had miliary TB with central nervous system involvement. The PR occurred at a median of 42 days (range 23-53 days) after initiating therapy. Corticosteroids were started when PR was suspected, at a median dose of 1mg/kg/day. Clinical and radiological improvement was noted in all cases, with a median clinical regression time of 10.5 days (range 3-15 days) and a median radiological regression time of 45 days (range 26-105 days). No sequelae were described in any patient.

CONCLUSIONS

PR in immunocompetent children during anti-tuberculosis treatment is not such an unusual reaction. Treatment with corticosteroids may be useful for the resolution of PR.

Paradoxical reaction to antituberculosis therapy in a patient with lupus vulgaris

Patients receiving treatment for tuberculosis may experience an unexpected deterioration of their disease; this is known as a paradoxical reaction. We present the case of a 59-year-old man with lupus vulgaris who experienced a paradoxical deterioration of cutaneous lesions after starting antituberculosis therapy. The reaction was self-limiting; the lesions gradually improved, and the final outcome was very good. Paradoxical reactions are well-known in patients with human immunodeficiency virus (HIV) infection who start antiretroviral therapy, but they can also occur in non-HIV-infected patients with tuberculosis who start antituberculosis therapy. In the literature reviewed, paradoxical reactions involving skin lesions were described in patients with miliary tuberculosis. The case we report is the first of a paradoxical reaction in lupus vulgaris. The increasing frequency of tuberculosis in Spain could lead to a rise in the number of paradoxical reactions.

Serial interferon-gamma release assays after chemoprophylaxis in a tuberculosis outbreak cohort

PURPOSE

Interferon-gamma release assay (IGRA) results have been suggested as a surrogate marker of treatment response in latent tuberculosis infection (LTBI). However, data have not been consistent, and most previous studies focused on participants taking isoniazid prophylaxis. The aim of this study was to elucidate the changes in the IGRA results in patients who underwent chemoprophylaxis with isoniazid and rifampicin daily for 3 months.

METHODS

In a TB outbreak cohort, 26 asymptomatic close contacts with normal chest radiographs and positive QuantiFERON-TB Gold In-Tube assay (QFT-GIT) results were recruited. These patients were treated with isoniazid and rifampicin daily for 3 months. The QFT-GIT was repeated at 3 and 6 months following treatment initiation.

RESULTS

Compared with the initial QFT-GIT results (3.59 ± 3.39 IU/mL), the interferon-gamma (IFN-γ) levels had decreased significantly at 6 months (0.84 ± 1.14 IU/mL; P = 0.005), but not at 3 months (3.58 ± 3.64 IU/mL; P = 0.98). Reversions occurred in seven (26.9 %) patients at 3 months and in an additional two participants at 6 months; a total of nine participants (34.6 %) had reversions. Recent conversion was associated with reversion of the test results (odds ratio 26.3, 95 % confidence interval 3.04-226.6).

CONCLUSION

Chemoprophylaxis with isoniazid and rifampicin generally decreased IFN-γ levels among tuberculosis contacts. However, only a small portion of participants achieved reversion.