Paradoxical response in spinal tuberculosis: Lessons learnt

Patients with spinal tuberculosis started on antituberculous treatment (ATT) empirically and showing increasing size of the lesion on follow-up are a treatment challenge. We describe our experience in managing such cases.

We treated 80 patients with spinal tuberculosis at our institute from January 2012 to June 2014. Of these, 50 were managed by surgical intervention and the rest 30 were managed conservatively only on anti-tubercular drugs. Six patients out of these 30 patients, showed a paradoxical increase in the size of lesion without any neurological deficits after 3 months of starting ATT. Surgical intervention was done in three cases, whereas other three were managed by ultrasound-guided tapping of the lesion with continuation of ATT.

There was an improvement in the symptoms with weight gain and normalcy of appetite. However, all these patients had lymphopenia on differential leukocyte counts at the outset which normalized at 3 months.

The mainstay of management of paradoxical response in spinal tuberculosis should be conservative with drainage or aspiration of abscesses along with the continuation of ATT. Surgical decompression and stabilization may be necessary in few cases who develop new neurological deficits or deformity or instability.