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Infliximab therapy in two cases of severe neurotuberculosis paradoxical reaction

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Clinical record

Patient 1

A 60-year-old HIV-negative woman presented with a week’s history of fever, vomiting and confusion, followed by progressive personality change. On admission, she was noted to have urinary retention, left oculomotor nerve palsy and an upgoing right plantar response. A magnetic resonance image (MRI) of the brain showed leptomeningeal enhancement with gyral swelling and subtle cortical T2 signal hyperintensity in the right frontal lobe, suggesting meningoencephalitis. Cerebrospinal fluid (CSF) cultures grew fully susceptible Mycobacterium tuberculosis. Antituberculous therapy was started with isoniazid, rifampicin, ethambutol and pyrazinamide, plus dexamethasone. CSF cultures tested negative by Week 1. Over the next month, she had ongoing fevers and fluctuating conscious state. High CSF pressures necessitated ventriculoperitoneal (VP) shunting. An MRI 3 months into therapy showed numerous granulomas, microabscesses and infarcts. Her condition failed to improve with a further course of dexamethasone, and an MRI at 5 months showed increasing size and number of granulomas, with worsening oedema and midline shift (Figure 1, A). She was given a trial of three doses of infliximab 10 mg/kg, 1 month apart, resulting in marked improvement in neurological status and radiological findings (Figure 1, B). She regained movement of her limbs, opened her…