Paradoxical worsening of brain tuberculomas during treatment.

A N 8-YEAR-OLD BOY being treated with c h e m o t h e r a p y owing to stage IIIA Hodgkin disease was admitted to the pediatric intensive care unit because of fever and respiratory distress in the previous 2 weeks. Despite full antibiotic coverage, his condition worsened, and 7 days later, he underwent a lung biopsy. On the next day, he developed headache, vomiting, and progressive coma. A brain magnetic resonance image showed multiple small, round T2-weighted and fluid-attenuated inversion recovery hyperintense lesions (Figure, A) suggestive of brain tuberculomas. A lumbar puncture revealed a white blood cell count of 10 cells/mm, protein level of 40 mg/dL, and glucose level of 37 mg/dL. Stains and culture results for bacteria, mycobacteria, and fungi were negative as well as cerebrospinal fluid Mycobacterium tuberculosis polymerase chain reaction. Tuberculosis was diagnosed from the lung biopsy specimen and the patient gradually improved after starting treatment with rifampicin, ethambutol hydrochloride, streptomycin, and pyrazinamide. He was discharged home 3 weeks later, but 1 week after, he presented with new onset of headache, vomiting, low-grade fever, and mild right hemiparesis. A new brain magnetic resonance image disclosed worsening of the swelling around the tuberculomas (Figure, B), and a diagnosis of paradoxical reaction to tuberculosis was made. Neurological symptoms disappeared after 2 weeks of steroid treatment. Five months later, all brain lesions had disappeared on a follow-up magnetic resonance image (Figure, C). COMMENT