Spinal cord tuberculosis: a paradoxical response to antituberculous therapy.

To cite: Sahu R, Chaudhari TS, Junewar V, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014203639 DESCRIPTION A 22-year-old man, with a known case of definitive tuberculous meningitis (TBM) on antitubercular therapy (ATT) for 5 months, presented with subacute onset sensorimotor paraparesis with urinary urgency since 1 month. He had also received dexamethasone therapy 0.4 mg/kg/24 h for 1 month followed by reducing course over next 2 weeks as per British Infection Society guidelines. MRI of the spine revealed a ring enhancing intramedullary lesion at D4 level suggestive of tuberculoma alongwith extramedullary meningeal based heterogeneously enhancing lesion extending from D6 to D10 level suggestive of arachnoiditis (figures 1 and 2). Paradoxical reaction in TBM refers to type IV hypersensitivity reaction manifesting as new tuberculoma and/or arachnoiditis during the course of antituberculous chemotherapy. The host immune response responsible for hypersensitivity reaction to protein derivatives of mycobacteria is resolved after starting chemotherapy. As per previous literature, spinal tuberculosis is an unusual complication of TBM. Spinal cord tuberculosis as a paradoxical immune response should be known as an unusual but a possible complication of TBM. Recommendation