Severe Paradoxical Manifestations in an Immunocompetent Young Female With Tuberculous Meningitis

A paradoxical reaction, in patients with tuberculous meningitis, is described as either worsening of pre-existing tuberculous lesions or the appearance of new tuberculous lesions after initial improvement with anti-tuberculosis treatment. The condition is often difficult to predict. When severe, it may also result in considerable neurological morbidity and even death. We aim to report such a rare case of severe paradoxical response in a young female with tuberculous meningitis. An 18-year-old female developed severe headache, vomiting, altered sensorium, decreased vision, and paraparesis. She was on anti-tuberculosis treatment (ATT) for tuberculous meningitis for the past two months. Radiological findings revealed tuberculomas in the left cerebral and cerebellar hemispheres, adhesive arachnoiditis in the cervical spine, and moderate communicating hydrocephalus. Visual evoked potential tests provided electrophysiological evidence of optic neuropathy in the left eye. The appearance of new (tuberculoma and adhesive arachnoiditis in the cervical spine), as well as aggravation of pre-existing tuberculous lesions (worsened hydrocephalus and worsened clinical features), were evident in the patient, suggestive of severe paradoxical response (with HIV negative serology). The patient was treated with corticosteroids, and antibiotics, and continued the ATT programme in a conservative manner. Nonetheless, as the patient had severe CNS manifestations, severe disabilities (poor vision, paraparesis, or quadriparesis) and fatalities were inevitable. Notwithstanding, it is crucial to recognize the paradoxical manifestations of tuberculous meningitis to avoid misleading diagnoses and unwarranted management strategies.