Paradoxical Reaction to the Antituberculous Drugs in a Patient Without HIV Infection

Abstract

Introduction. Tuberculosis is an infectious disease and a public health concer due to its worldwide impact, which has led to the establishment of clear treatment guidelines that include standardized management. The development of a paradoxical reaction to the antituberculous drugs is an unusual often unsuspected but potentially fatal complication that is more frequent in patients with HIV infection. Description. The case of a 47-year-old male patient with antecedents of systemic erythematosus lupus in treatment with prednisolone, chloroquine and mycophenolate, who consulted for fever associated with dysuria, polyaquiuria and scaling skin lesions. During the hospitalization, he presented cough and dyspnea. It was suspected a pulmonary infectious process and alcohol-resistant acid bacilli were identified by lung biopsy before negative initial tests in bronchoalveolar lavage. Treatment was initiated with isoniazid, rifampicin, pyrazinamide, ethambutol and macrolide, with initial symptomatic improvement but after one month of treatment presented clinical deterioration. Random micronodules suggestive of miliary tuberculosis were documented with evidence of alcohol-resistant acid bacilli in a new biopsy. Drug resistance was ruled out with Genexpert PCR. Treatment with steroids was started and the patient`s condition improved. Discussion. A clinical and / or imaging deterioration, or the appearance of new lesions in patients with medication to treat tuberculosis, with an initial improvement of symptoms may be secondary to a paradoxical reaction to tuberculosis treatment. These types of reactions are more frequent in patients with HIV infection. The suggested pathophysiology proposes as a cause the recovery of the immune system during the course of treatment due to an exaggerated inflammatory response that worsens the tissue damage secondary to tuberculosis infection, as well as the rapid death of mycobacteria that produces a release of microbial components that stimulate a great inflammatory response. The clinical and radiological findings are very variable and usually respond to symptomatic management. In severe cases, steroid could be used. Hematogenous spread as a manifestation of a paradoxical reaction to tuberculosis treatment in a patient with pulmonary tuberculosis is not frequent and represents an unusual finding.