Paradoxical reaction in HIV negative tuberculous meningitis

J Neurol Sci. 2014 May 15;340(1-2):26-36. doi: 10.1016/j.jns.2014.03.025. Epub 2014 Mar 19.


This review focusses on paradoxical reactions occurring during the treatment of tuberculous meningitis (TBM) in human immunodeficiency virus-negative cases. A paradoxical reaction is defined as the worsening of a pre-existing lesion or the appearance of new lesion in a patient whose clinical symptoms initially improved with anti-tuberculosis treatment. A number of different paradoxical reactions have been reported in patients with TBM including expansion of existing cerebral tuberculomas, and appearance of new tuberculomas, hydrocephalus, and optochiasmatic and spinal arachnoiditis. While the exact mechanism of paradoxical reactions is uncertain, an exaggerated immune reaction against Mycobacterium tuberculosis-associated antigens is currently the most accepted theory for tuberculous paradoxical reaction. Corticosteroids are considered to have a beneficial effect in the management of paradoxical reactions. Immuno-modulatory drugs, including tumor necrosis factor-α antagonists, thalidomide and interferon-γ have been used in isolated cases with more severe forms of paradoxical reactions.

Keywords: Central nervous system; Corticosteroids; Hydrocephalus; Mycobacterium tuberculosis; Tuberculoma; Tuberculosis.

Publication types

  • Review

MeSH terms

  • Antitubercular Agents / adverse effects*
  • Brain Diseases* / chemically induced
  • Brain Diseases* / etiology
  • Brain Diseases* / pathology
  • Central Nervous System / drug effects
  • Central Nervous System / microbiology
  • Central Nervous System / pathology
  • Humans
  • Mycobacterium tuberculosis / pathogenicity
  • Tuberculosis, Meningeal / drug therapy*
  • Tuberculosis, Meningeal / physiopathology*


  • Antitubercular Agents