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      Paradoxical reactions in ocular tuberculosis

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          Abstract

          Paradoxical reactions following initiation of anti-tubercular therapy have been documented most often in extrapulmonary tuberculosis. A combination of factors such as delayed hypersensitivity, decreased suppressor mechanisms, and an increased response to mycobacterial antigens mediated by the host’s immune system have been implicated in the development of these reactions. Similar worsening in patients with ocular tuberculosis while on treatment has been described. It is therefore important for the clinician to be aware of this occurrence, as prompt recognition and timely institution of corticosteroids and immunosuppressants can lead to restoration of vision. In these patients, an alteration or discontinuation of anti-tubercular therapy may not be indicated.

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          Intraocular tuberculosis--an update.

          Vishali Gupta, Amod Gupta, Narsing A Rao (2007)
          The lack of any uniform diagnostic criteria for intraocular tuberculosis, in either immunocompetent or immunocompromised individuals, has contributed to the confusion regarding diagnosis and management. However, recent studies addressing the clinical significance of purified protein derivative test results, computerized tomography of the chest, and molecular diagnostic procedures have provided a new approach to establishing the diagnosis of ocular tuberculosis. The current review focuses on the diagnostic modalities used for the clinical management of intraocular tuberculosis, with the emphasis on diagnostic criteria, various clinical features, and treatments recommended in recent publications. Furthermore, the current review addresses the diagnostic criteria for intraocular tuberculosis, the spectrum of tuberculosis in patients with AIDS and in those on anti-tumor necrosis factor agents, and management of drug-resistant tuberculosis.
          Article 0 comments Cited 150 times – based on 0 reviews     Review now
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            Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS.

            D Ashkin, A E Pitchenik, M Narita … (1998)
            Transient worsening of tuberculous symptomatology and lesions following antituberculous therapy (paradoxical response) has previously been described as a rare occurrence. To determine the incidence of paradoxical responses in patients with AIDS and TB who are treated with antituberculous therapy and subsequently with combination antiretroviral therapy (ARV), we conducted a prospective study of 33 HIV-seropositive TB patients treated with anti-TB therapy and antiretroviral therapy (Group 1) compared with 55 HIV-seronegative TB patients treated with anti-TB therapy (Group 2) and 28 HIV-seropositive TB patients treated with anti-TB therapy but not on antiretrovirals (historical control; Group 3). In Group 1 patients, paradoxical responses were temporally more related to the initiation of ARV than to the initiation of anti-TB therapy (mean +/- SD: 15 +/- 11 d versus 109 +/- 72 d [p < 0.001]) and occurred much more frequently (12 of 33; 36%) compared with Group 2 (1 of 55; 2%) (p < 0.001) or with Group 3 (2 of 28; 7%) (p = 0.013). The majority of patients who experienced paradoxical responses and received tuberculin purified protein derivative (PPD) in Group 1 had their tuberculin skin tests convert from negative to strongly positive after ARV. These observations suggest that a paradoxical response associated with enhanced tuberculin skin reactivity may occur after the initiation of ARV in HIV-infected TB patients. Furthermore, the skin test conversion after the initiation of ARV may have important public health implications.
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              Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients.

              Hunter K. L. Yuen, Gilbert Lee, P. Ho … (2002)
              Paradoxical deterioration during antituberculosis therapy, defined as the clinical or radiological worsening of pre-existing tuberculous lesions or the development of new lesions in a patient who initially improves, remains a diagnostic dilemma. Although different clinical presentations of paradoxical response have been described, a systematic analysis of the entity in non-HIV-infected patients is lacking. Reported here are two cases of paradoxical deterioration in which sequential changes in lymphocyte counts and tuberculin skin test results are emphasized. In addition, 120 episodes of paradoxical response after antituberculosis treatment were reviewed. Of the total 122 episodes, 101 (82.8%) were associated with extrapulmonary tuberculosis. The median time from commencement of treatment to paradoxical deterioration was 60 days. The median time to onset of central nervous system manifestations (63 days) was longer than the time to onset of manifestations at other sites (56 days) ( P=0.02). Development of new lesions in anatomical sites other than those observed at initial presentation was observed in 31 (25.4%) episodes. A surge in the lymphocyte count, accompanied by an exaggerated tuberculin skin reaction, was observed in our patients during the paradoxical deterioration, analogous to the findings in HIV-positive patients. Treatment of the paradoxical response included surgical intervention (60.7%) and administration of steroids (39.3%). The use of steroids appeared to be safe in this series, as 95% of the Mycobacterium tuberculosis isolates were susceptible to first-line antituberculosis therapy.
              Article 0 comments Cited 81 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Sudha K. Ganesh: 91-044-28271616 , drskg@snmail.org
                Sharanya Abraham: drsaa@snmail.org
                Sridharan Sudharshan: drssn@snmail.org
                Journal
                Journal ID (nlm-ta): J Ophthalmic Inflamm Infect
                Journal ID (iso-abbrev): J Ophthalmic Inflamm Infect
                Title: Journal of Ophthalmic Inflammation and Infection
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Electronic): 1869-5760
                Publication date (Electronic): 6 September 2019
                Publication date PMC-release: 6 September 2019
                Publication date Collection: 2019
                Volume: 9
                Electronic Location Identifier: 19
                Affiliations
                ISNI 0000 0004 1767 4984, GRID grid.414795.a, Medical Research Foundation, , Sankara Nethralaya, ; 18, College Road, Chennai, 600 006 India
                Article
                Publisher ID: 183
                DOI: 10.1186/s12348-019-0183-x
                PMC ID: 6730739
                PubMed ID: 31493128
                SO-VID: f39d4581-cb26-4fc7-ae07-ff30d97e7688
                Copyright © © The Author(s). 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 2 February 2019
                Date accepted : 9 August 2019
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: ocular tuberculosis,paradoxical reaction,paradoxical worsening,corticosteroids,immunosuppressives,syphilis,hiv,jarisch–herxheimer reaction,immune-reconstitution inflammatory syndrome (iris),anti-tubercular therapy
                Data availability:
                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: ocular tuberculosis, paradoxical reaction, paradoxical worsening, corticosteroids, immunosuppressives, syphilis, hiv, jarisch–herxheimer reaction, immune-reconstitution inflammatory syndrome (iris), anti-tubercular therapy

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