102 Late-onset paradoxical reactions in neurotuberculosis presenting 18 months and 20 years after treatment

IntroductionParadoxical reactions (PRs) during treatment of neurotuberculosis are common but late-onset PRs after completion of anti-tuberculous treatment are reported very rarely. The management of late-onset PRs is challenging as excluding other diagnoses is difficult without invasive testing.MethodsTwo cases of late-onset PRs after treatment for neurotuberculosis are reported. The timing of onset, clinical and radiological features of these PRs are described and the diagnostic work up and outcomes after empiric immunosuppression reviewed.ResultsA 24-year-old woman presented with right-sided focal motor seizures 18 months after receiving anti-tuberculous treatment for neurotuberculosis. MRI showed enlargement of a previous left frontal tuberculoma with extensive oedema. A biopsy was not performed as the lesion involved eloquent brain and the patient declined a lumbar puncture. She was treated empirically with corticosteroids for six months and had clinical and radiological improvement.A 56-year-old woman presented with left leg weakness and numbness 20 years after treatment for multiple cerebral tuberculomas. MRI showed a new confluent area of T2 hyperintensity in the right frontal and parietal lobes. Cerebrospinal fluid was negative for acid-fast bacilli. She was treated with corticosteroids for 2 months with progressive improvement.ConclusionsLate onset PRs to neurotuberculosis can occur months to years after completing anti-tuberculous therapy. Recognising this entity is important so unnecessary treatments and brain biopsy may be avoided. Empiric immunosuppression with corticosteroids appears to be safe if early follow up and repeat imaging is arranged.