Paradoxical Reaction With Intercostal Lymphadenopathy in Tuberculous Pleurisy

Paradoxical reaction (PR) is defined as the clinical or imaging worsening of tuberculosis lesions or the emergence of new lesions after anti-tuberculosis therapy. Although additional treatments, including corticosteroids, may be considered in severe cases, the mainstay management of a PR is close monitoring, as the condition is generally self-limited. Radiographic presentations are diverse, and currently, no specific radiographic features of this condition have been identified, which may lead to misdiagnosis as treatment failure, drug-resistant tuberculosis, or another infection. PRs in tuberculous pleurisy, once considered rare, typically manifest as increased pleural effusion or progression of infiltration. We present a rare case of tuberculous pleurisy in which intercostal lymphadenopathy enlargement occurred as a PR on the 22nd day of anti-tuberculosis therapy. The symptoms did not significantly affect the patient's quality of life, physical activity, or respiratory function, and the patient was closely monitored without modifying treatment or adding corticosteroids, showing improvement on the 34th day of anti-tuberculosis therapy. Two years have passed after the completion of treatment, and no recurrence of tuberculosis or PR has been observed. This case highlights the importance of clinician vigilance for PRs in tuberculosis management. During treatment for tuberculous pleurisy, unexplained intercostal lymphadenopathy should raise suspicion of a PR, and close monitoring without invasive tests or treatments is recommended.