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Abstract
Paradoxical reaction during antituberculosis therapy is defined as aggravation of preexisting tuberculous lesions or the development of new lesions. A 24-year-old female college student diagnosed with abdominal and pulmonary tuberculosis presented with fever and abdominal pain after having been treated with antituberculosis agents for 4 months. Tuberculous mesenteric lymphadenitis was suspected on abdominal CT scan and enlarged necrotic abscess was also present. These findings were considered to be due to paradoxical reaction rather than treatment failure during antituberculosis treatment. Although laparoscopic bowel adhesiolysis and abscess drainage were performed, high fever and severe abdominal pain did not improve. However, the patient eventually made a completely recovery after corticosteroid therapy combined with antituberculosis agents. Herein, we report a case of paradoxical reaction which developed in a patient with abdominal and pulmonary tuberculosis during antituberculosis therapy.
References
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Fig. 1.
Chest CT findings. (A) Chest CT shows ill-defined patchy consolidation and small nodules in the right upper lobe. (B) Four months after initiation of antituberculosis therapy, previous lesion is markedly reduced.
Fig. 2.
Abdominal CT findings. (A) About 1-cm sized lymphadenopathy with multiple lymphadenopathies is noted on the ileocecal area (arrow).(B) Four months after initiation of antituberculosis treatment, about 4-cm sized conglomerated lymph node with central necrosis is detected on the ileocecal area (arrow). (C) One month after laparoscopic drainage and adjuctive corticosteroid therapy, the conglomerated mass is reduced (arrow). (D) One year after laparoscopic drainage and adjuctive corticosteroid treatment, the previous lesion is decreased to normal range.
Fig. 3.
Colonoscopic and microscopic findings. (A) Exudate covered shallow ulcer is shown on terminal ileum. (B) Presence of chronic granuloma with epithelioid cells (arrows) is compatible with intestinal tuberculosis (H&E stain, ×200).
Fig. 4.
Histological finding of peritoneal wall. Peritoneal biopsy shows chronic granulomatous inflammation with epithelioid cell (arrows) and necrosis (asterisk), consistent with tuberculous peritonitis (H&E stain, ×200).
Table 1.
Clinical Feature of Cases of Abdominal Tuberculosis Developed during Anti-TB Therapy as PR
| Reference | Site of initial involvement | Time to onset of PR (day) | Presentation of PR | Treatment (duration or dose) | Outcome |
|---|---|---|---|---|---|
| Cheng et al.4 | Lung, cervical and mediastinal LN | 56 | Sudden onset of acute abdominal pain, vomiting; CT showed thickening of wall of terminal ileum. | Continuation of anti-TB therapy | Recovery |
| Pelvic, peritoneum, paravertebral abscess at right-sided T6 and left-sided T8-10 | 32 | Acute abdominal pain; Urgent laparotomy revealed multiple ulcers over small bowel, multiple mesenteric lymph nodes, abscess cavity over pelvis with pus. | Laparotomy with small bowel resection and drainage of intra-abdominal pus | Recovery | |
| Ahn et al.7,a | Lung, pleura | 150 | Acute abdominal pain; CT showed irregular peritoneal line and ascites and abscess. | Abscess drainage Continuation of anti-TB therapy (19 mo) Steroidb | Recovery |
| Kasahara et al.8 | Lung, terminal ileum | 150 | Abdominal distension; CT showed ascites, calcification of LN. | Continuation of anti-TB therapy (12 mo) Operation c | Recovery |
| Kim et al.9 | Pleura | 60 | Acute abdominal pain; CT showed ascites, smudge pattern of peritoneum. | Continuation of anti-TB therapy (9 mo) | Recovery |
| Bukharie10 | Mesenteric LN | 10 | Recurred fever, abdominal pain; CT showed enlargement of previous mass with central necrosis. | Steroid (PRD 60 mg/d for 2 mo) Continuation of anti-TB therapy (10 mo) | Recovery |
| Lee et al.11 | Peritoneum, mesenteric LN, ileocecal valve, colon | 150 | Obstructive jaundice; CT showed compression of CBD due to enlarged LN of periportal area. | Steroid (PRD 30 mg/d for 1 mo) ERBD | Recovery |
| Colonoscopy showed a new ulcer lesion of ascending colon. | Continuation of anti-TB therapy (9 mo) | ||||
| Dixit et al.12 | Pleura | 42 | Gradually left side abdominal pain; CT showed miliary sized abscesses on spleen. | Steroid (PRD 40 mg/d) Continuation of anti-TB therapy (6 mo) | Recovery |
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