Milliary tuberculosis with unusual paradoxical response at 3 weeks of antituberculous treatment

Milliary Tuberculosis (TB) occurs through lymphohaematogenous dissemination of M. tuberculosis and paradoxical response (PR) is a recognized feature. Respiratory failure, choroid tubercles and brain tuberculomas are some of the complications. Brain tuberculomas mainly occur in the cerebrum, cerebellum, where as involvement of the brainstem is rare. A 31 years old female presented with history of ill health, easy fatigability, excessive sweating and fever of one month duration, dry cough for one week and shortness of breath for 3 days. Provisional diagnosis was disseminated TB complicated by hypoxemic respiratory failure and bilateral choroid tubercles. She was started on anti-TB treatment with adjuvant steroids. The initial response to treatment was remarkable but after about 3 weeks of anti-TB therapy, she suddenly deteriorated developing spastic ataxia. After exclusion of other possible causes she was successfully treated under the impression of having PR.