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Kaya A, Altınkaynak M, Keskin F, Özdemir G, Kaya SY, Mert A. Paradoxical psoas and subcutaneous abscesses developing on anti-tuberculous treatment: A case report and literature review. J Natl Med Assoc 2023; 115:392-397. [PMID: 37308345 DOI: 10.1016/j.jnma.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/08/2023] [Accepted: 05/15/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Abdurrahman Kaya
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey.
| | - Merve Altınkaynak
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey
| | - Feyza Keskin
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey
| | - Gülhan Özdemir
- Department of Infectious Diseases, İstanbul Training and Research Hospital, Istanbul, Turkey
| | - Sibel Yıldız Kaya
- Department of Infectious Diseases, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Turkey
| | - Ali Mert
- Infectious Diseases and Clinical Microbiology, Faculty of Medicine, İstanbul Medipol University, Turkey
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2
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Mert A, Bilir M, Ozaras R, Tabak F, Goksel S, Senturk H. A Rare Complication of Miliary Tuberculosis : Intestinal Perforation. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- A. Mert
- Departments of Infectious Diseases, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - M. Bilir
- Departments of Internal Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - R. Ozaras
- Departments of Internal Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - F. Tabak
- Departments of Infectious Diseases, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - S. Goksel
- Departments of Pathology, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - H. Senturk
- Departments of Internal Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
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3
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Tokuyama Y, Matsumoto T, Kusakabe Y, Yamamoto N, Aihara K, Yamaoka S, Mishima M. Ground-glass opacity as a paradoxical reaction in miliary tuberculosis: A case report and review of the literature. IDCases 2020; 19:e00685. [PMID: 31908948 PMCID: PMC6939021 DOI: 10.1016/j.idcr.2019.e00685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/28/2019] [Accepted: 11/28/2019] [Indexed: 11/19/2022] Open
Abstract
A paradoxical reaction (PR) is an excessive immune response occurring during antitubercular therapy (ATT), but is rare in patients with miliary tuberculosis. A 78-year-old woman complained of general malaise, loss of appetite, and fever for 10 days. Chest computed tomography (CT) showed diffuse, bilateral, discrete miliary nodules. The patient was treated with ATT for miliary tuberculosis. Nine days after starting the treatment, she developed a spiking fever and worsening malaise. Repeat CT showed new localized ground-glass opacity (GGO) in the right upper lobe. After excluding possible etiologies, she was diagnosed with PR due to ATT. She was successfully managed with oral prednisolone while continuing ATT. The GGO diminished and did not recur after discontinuation of the steroids. We reviewed 28 reported cases of miliary tuberculosis with a PR in patients not infected with human immunodeficiency virus. Those not on immunosuppressive therapy were likely to develop a PR early. This case illustrates that a PR may present as localized GGO in miliary tuberculosis in the lung of patients treated with ATT. In cases of a PR with marked symptoms, steroid therapy may be valuable.
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Affiliation(s)
- Yuki Tokuyama
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
| | - Takeshi Matsumoto
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
| | - Yusuke Kusakabe
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
| | - Naoki Yamamoto
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
| | - Kensaku Aihara
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
| | - Shinpachi Yamaoka
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Saiseikai-Noe Hospital, Osaka, Japan
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Pornsuriyasak P, Suwatanapongched T. Thoracic manifestations of paradoxical immune reconstitution inflammatory syndrome during or after antituberculous therapy in HIV-negative patients. Diagn Interv Radiol 2016; 21:134-9. [PMID: 25698091 DOI: 10.5152/dir.2014.14212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is a consequence of exaggerated and dysregulated host's inflammatory response to invading microorganism, leading to uncontrolled inflammatory reactions. IRIS associated with tuberculosis (TB) is well recognized among human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy, but it is less common among HIV-negative patients. IRIS can manifest as a paradoxical worsening or recurring of preexisting tuberculous lesions or development of new lesions despite successful antituberculous treatment. Hence, the condition might be misdiagnosed as superimposed infections, treatment failure, or relapse of TB. This pictorial essay reviewed diagnostic criteria and various thoracic manifestations of the paradoxical form of TB-associated IRIS (TB-IRIS) that might aid in early recognition of this clinical entity among HIV-negative patients. The treatment and outcomes of TB-IRIS were also discussed.
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Affiliation(s)
- Prapaporn Pornsuriyasak
- Division of Pulmonary and Critical Care, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok.
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Lanzafame M, Vento S. Tuberculosis-immune reconstitution inflammatory syndrome. J Clin Tuberc Other Mycobact Dis 2016; 3:6-9. [PMID: 31723680 PMCID: PMC6850228 DOI: 10.1016/j.jctube.2016.03.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 02/26/2016] [Accepted: 03/04/2016] [Indexed: 12/24/2022] Open
Abstract
Tuberculosis-immune reconstitution inflammatory syndrome is an excessive immune response against Mycobacterium tuberculosis that may occur in either HIV-infected or uninfected patients, during or after completion of anti-TB therapy. In HIV-infected patients it occurs after initiation of antiretroviral therapy independently from an effective suppression of HIV viremia. There are two forms of IRIS: paradoxical or unmasking. Paradoxical IRIS is characterized by recurrent, new, or worsening symptoms of a treated case. Unmasking IRIS is an antiretroviral-associated inflammatory manifestation of a subclinical infection with a hastened presentation. The pathogenesis is incompletely understood and the epidemiology partially described. No specific tests can establish or rule out the diagnosis. Treatment is based on the use of anti-tuberculosis drugs sometime with adjunctive corticosteroids. Mortality is generally low.
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Affiliation(s)
| | - Sandro Vento
- Department of Medicine, School of Medicine, Nazarbayev University, Astana, Kazakhstan
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Ibraheem T. Paradoxical response to antituberculous therapy. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gupta A, Srivastava VK, Khanna VN, Rizvi I. Paradoxical reaction to antitubercular therapy in miliary tuberculosis. BMJ Case Rep 2012; 2012:bcr0320126142. [PMID: 22948985 PMCID: PMC4543002 DOI: 10.1136/bcr-03-2012-6142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 18-year-old boy presented with fever, weight loss and loss of appetite for 6 months duration. Investigation revealed raised erythrocyte sedimentation rate, negative sputum smear examination for acid-fast bacilli, x-ray and high-resolution CT chest showed bilateral, diffuse infiltration of lung parenchyma with miliary shadows. The patient was treated as a case of miliary tuberculosis with antitubercular therapy (ATT). On the 10th day of treatment the patient developed high-grade fever, cough and breathlessness. Chest x-ray showed an increased infiltration of lung parenchyma. The patient was diagnosed as a case of paradoxical reaction to ATT and was managed successfully with steroids.
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Affiliation(s)
- Ankush Gupta
- Department of Medical Division, Military Hospital Jodhpur, Jodhpur, Rajasthan, India.
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Hassan TM, Keane J, McLaughlin AM. Paradoxical reaction causing tuberculous arthritis and soft-tissue abscess in a non-HIV infected, lymphopenic, vitamin D deficient patient with disseminated tuberculosis. A coincidence or an immunological conundrum? Joint Bone Spine 2011; 78:322-3. [DOI: 10.1016/j.jbspin.2010.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 11/09/2010] [Indexed: 11/30/2022]
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Cheng VCC, Wu AKL, Hung IFN, Tang BSF, Lee RA, Lau SKP, Woo PCY, Yuen KY. Clinical Deterioration in Community Acquired Infections Associated with Lymphocyte Upsurge in Immunocompetent Hosts. ACTA ACUST UNITED AC 2009; 36:743-51. [PMID: 15513401 DOI: 10.1080/00365540410022602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Clinical deterioration during the course of community-acquired infections can occur as a result of an exaggerated immune response of the host towards the inciting pathogens, leading to immune-mediated tissue damage. Whether a surge in the peripheral lymphocyte count can be used as a surrogate marker indicating the onset of immunopathological tissue damage is not known. In this study, we report the clinical presentations and outcomes of a cohort of immunocompetent patients with non-tuberculous community acquired infections who experienced clinical deterioration during hospital stay (n=85). 12 (14.1%) patients had a surge in lymphocyte count preceding their clinical deteriorations, and their diagnoses included viral pneumonitis , viral encephalitis , scrub typhus , leptospirosis , brucellosis , and dengue haemorrhagic fever . The clinical manifestations during deterioration ranged from interstitial pneumonitis , airway obstruction , CNS disturbances , and systemic capillary leak syndrome , all of which were thought to represent immunopathological tissue damages. When compared with patients without lymphocyte surge, these patients were more likely to be infected with fastidious/viral pathogens (0 vs 12; p<0.05), in addition to having lower mean baseline lymphocyte counts (403+/-181 vs 1143+/-686 cells/microl; p<0.05). We postulate that the peripheral lymphocyte count may be a useful surrogate marker indicating the presence of immunopathological damage during clinical deterioration in certain infectious diseases.
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Affiliation(s)
- Vincent C C Cheng
- Division of Infectious Diseases, Centre of Infection Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
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10
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Isolated skin ulcers due to Mycobacterium tuberculosis in a renal allograft recipient. ACTA ACUST UNITED AC 2007; 3:688-93. [DOI: 10.1038/ncpneph0661] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 08/14/2007] [Indexed: 01/26/2023]
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Seyahi N, Apaydin S, Kahveci A, Mert A, Sariyar M, Erek E. Cellulitis as a manifestation of miliary tuberculosis in a renal transplant recipient. Transpl Infect Dis 2005; 7:80-5. [PMID: 16150096 DOI: 10.1111/j.1399-3062.2005.00095.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cutaneous involvement is an unusual presentation of tuberculosis (TB) and is rarely reported in renal transplant recipients. We describe a 37-year-old renal transplant recipient with disseminated Mycobacterium tuberculosis infection that presented as cellulitis. The organism was isolated from tissue and blood cultures. The patient was treated with quadruple anti-TB therapy for 12 months. Anti-TB therapy led to a complete resolution of TB lesions. We also provide a review of the literature on cutaneous TB in renal transplant recipients. Skin TB in renal transplant recipients usually occurs with nontuberculous mycobacteria. The spectrum of the skin lesions can be quite different and can mimic bacterial infections. Mycobacteriosis should always be included in the differential diagnosis of a skin lesion in renal transplant recipients.
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Affiliation(s)
- N Seyahi
- Department of Nephrology, Istanbul University, Cerrahpasa Medical Faculty, Turkey.
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Cheng VCC, Yam WC, Woo PCY, Lau SKP, Hung IFN, Wong SPY, Cheung WC, Yuen KY. Risk factors for development of paradoxical response during antituberculosis therapy in HIV-negative patients. Eur J Clin Microbiol Infect Dis 2003; 22:597-602. [PMID: 14508660 DOI: 10.1007/s10096-003-0998-z] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The risk factors for development of paradoxical response were studied in a cohort of 104 patients with culture-documented Mycobacterium tuberculosis infection. Paradoxical deterioration occurred in 16 (15.4%) patients (case group) during antituberculosis therapy, involving lungs and pleura (n=4), spine and paraspinal tissue (n=5), intracranium (n=3), peritoneum (n=2), bone and joint (n=1), and lymph node (n=1). The median time from commencement of treatment to paradoxical deterioration was 56 days (range, 20-109 days). Compared with 53 patients without clinical deterioration after antituberculosis therapy (control group), patients with paradoxical response were more likely to have extrapulmonary involvement (62.5% vs. 17.0%; P<0.05) at initial diagnosis, to have lower baseline lymphocyte counts (672+/-315 cells/microl vs. 1,328+/-467 cells/microl; P<0.001), and to exhibit a greater surge in lymphocyte counts (627+/-465 cells/microl vs. 225+/-216 cells/microl; P<0.05) during paradoxical response. Further studies on lymphocyte subsets and cytokine levels would be useful in understanding the exact immunological mechanisms involved in immunorestitution.
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Affiliation(s)
- V C C Cheng
- Division of Infectious Diseases, Center of Infection, University Pathology Building, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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Mert A, Ozaras R. Cutaneous tuberculosis from paradoxical expansion: a new category in the classification of cutaneous tuberculosis. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2002; 33:945. [PMID: 11868776 DOI: 10.1080/00365540110077100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Bukharie H. Paradoxical response to anti-tuberculous drugs: resolution with corticosteroid therapy. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2000; 32:96-7. [PMID: 10716088 DOI: 10.1080/00365540050164326] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
During the course of appropriate treatment, patients with tuberculosis occasionally have unusual paradoxical reactions, with transient worsening of lesions or the development of new lesions. A 23-y-old housewife presented with abdominal tuberculosis. She was treated with anti-tuberculous agents to which the micro-organisms were susceptible. During therapy, there was an expansion of her abdominal lesions and her symptoms worsened. However, with the addition of steroids and the continuation of the same anti-tuberculous agents the patient eventually recovered completely. We emphasize that the worsening of tuberculous lesions may occur during chemotherapy and does not necessarily indicate treatment failure. This phenomenon may be immunologically based.
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Affiliation(s)
- H Bukharie
- Department of Medicine, King Fahad Hospital of the University, Khobar, Saudi Arabia
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Mert A, Bilir M, Ozturk R, Tabak F, Ozaras R, Tahan V, Senturk H, Aktuglu Y. Tuberculous subcutaneous abscesses developing during miliary tuberculosis therapy. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2000; 32:37-40. [PMID: 10716075 DOI: 10.1080/00365540050164191] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Although rare, paradoxical subcutaneous abscesses may develop during appropriate treatment of miliary tuberculosis. While the pathogenesis of this phenomenon is not clear, some theories have been postulated. A case of a 37-y-old woman diagnosed as having miliary tuberculosis who developed subcutaneous abscesses within the 5 months of antituberculous treatment is described and all 6 similar cases published in English from 1954 to 1999 are discussed.
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Affiliation(s)
- A Mert
- Department of Internal Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Turkey
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Sotto A, Guillot B, Dandurand M, Jourdan J. Exacerbation of skin mycobacterial lesions under highly active antiretroviral therapy in an HIV-infected patient. AIDS 1999; 13:1790-1. [PMID: 10509588 DOI: 10.1097/00002030-199909100-00030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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