Grand Rounds

Paradoxical Adenopathy in a Child with Tuberculosis

Medical Sciences Department, Pediatric Oncall, Mumbai

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

Clinical Problem :
A 13½ years old girl suffering from tuberculosis {TB} presented with clinical deterioration. She was diagnosed as having tuberculous mediastinal adenopathy 7 months ago and was started on antituberculous therapy {ATT} {2 months of Isoniazid {H}, Rifampicin {R}, Pyrazinamide {Z} and Ethambutol {E} followed by continuation phase of HR}. However after 3 months of ATT, she developed cervical adenopathy for which a fine needle aspiration was done that did not grow any acid fast bacillus and child was continued on same ATT. After 5 months of ATT and no improvement in cervical adenopathy, child underwent an excision of the cervical gland and histopathology was suggestive of tuberculous abscess. On examination, her weight was 36 kg, height was 152 cm. She had midline suprasternal healing ulcer and other systems were normal. Child was thus continued on HR and total 9 months of ATT was given. She had a weight gain of 4 kg in the same period and was asymptomatic post treatment completion.

Were steroids indicated in this child_?

Discussion :
This child has a paradoxical reaction. Paradoxical reaction {PR} in tuberculosis is defined as the clinical or radiological worsening of pre-existing tuberculous lesion or development of new lesion in a patient who initially improves with anti-tuberculosis therapy in the absence of disease relapse. Paradoxical reactions are usually self-limiting. Sometimes corticosteroids are used for relieving paradoxical reaction and anti-tuberculous therapy {ATT} is continued. The rationale behind the use of adjuvant steroids lies in reducing the harmful effects of inflammation as the ATT kill the organisms. However, advantage of steroid for lymph node tuberculosis is unclear. In contrast to patients with intracranial upgrading reactions, most patients with lymph node TB who have a paradoxical reaction recover without developing severe sequelae. In addition, the simpler intervention of aspiration of pus is associated with fewer unwanted side effects than is steroid therapy. The use of aspiration has been reported to be a successful therapeutic intervention for suppurative post- bacille Calmette-Guérin adenitis, and similarly aspiration or excision is useful for the treatment of a paradoxical reaction in a patient with lymph node TB.

Correct Answers :  yes 65%
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