A Case of Paradoxical Reaction after Treatment of Eyelid Tuberculosis

Dear Editor, We hereby present a case of paradoxical reaction after treatment of eyelid tuberculosis (TB) with anti-TB medication. An 89-year-old man presented with painful eyelid swelling and erythema of his left eyelid, which initially developed one month earlier (Fig. 1A); he was otherwise in a healthy condition. No history of ocular trauma or operation was reported. At the time of his first visit, his corrected vision was 20 / 20 (Snellen visual acuity) in the right and 20 / 40 in the left eye. Low vision of the left eye was presumed to be attributed to a progressed cataract. Under slit-lamp examination, there were no definite abnormal oc-ular signs. He had moving pain, but no restriction of motion. On inspection, inflamed palpable mass was noted on the left upper and lower eyelid; however, he had no definite tenderness of the lesion. The laboratory data showed normal values (e.g., body temperature of 37°C) except a slightly elevated erythrocyte sedimentation rate of 25 mm/hr. For 3 days prior to referral to our hospital, his symptom had not been improved by intravenous administration of ceftriaxone 2 g/day. Orbit computed tomography scan with contrast showed no sign of abscess despite diffuse infiltration of upper and lower eyelids. We did a biopsy of the upper eyelid, where formation of granulation tissues was found. Pathology showed chronic nonspecific inflammation with granulomatous lesion without definite acid-fast bacilli. Under the diagnosis of anterior orbital inflammation , high dose steroid pulse therapy using 500 mg of methylprednisolone/day for 4 days was performed and the steroid dosage was tapered with oral prednisolone. Eyelid swelling and erythema improved by one month of steroidal treatment (Fig. 1B), however after discontinuation, symptoms recurred and became even worse. Biopsy was performed again under the suspicious of TB infection, and anti-TB medication, HERZ (isoniazid 300 mg, ethambutol 800 mg, rifampin 500 mg, and pyrazinamide 25 mg daily) was started immediately. The pathology result was caseous necrosis with few acid-fast bacilli (Fig. 1C), and the inter-feron gamma test showed was positive for the TB antigen 6.19 IU/mL. Anti-TB medication was administered for 3 weeks, however, the patient revisited the clinic complaining of serious pain and presenting skin necrosis with discharge (Fig. 1D). The patient was admitted for daily aseptic dressing of the wound and monitoring while on HERZ medication. Eyelid swelling improved slightly but wound dehiscence and oozing was aggravated 5 weeks after the initiation …