Paradoxical tuberculous reactions in HIV-infected patients.
OBJECTIVE
To report the occurrence of paradoxical tuberculous reactions in two patients co-infected with HIV/AIDS, and to review the literature on this subject.


METHODS
Two HIV-infected patients with miliary tuberculosis who developed expansion of tuberculous disease at a new site following initiation of anti-tuberculosis treatment, with or without antiretroviral treatment, and an additional 29 literature cases of HIV infection with paradoxical tuberculous reaction.


RESULTS
Index episodes of tuberculosis included pulmonary, nodal, cutaneous and miliary forms. Types of paradoxical reactions included enlargement of lymph nodes or appearance of new lymphadenopathy, radiographic worsening of pulmonary infiltrates or appearance of miliary infiltrates or pleural effusions, peritonitis, tenosynovitis, worsening or development of new soft tissue lesions, and appearance of new contrast-enhancing intracranial tuberculomas. The occurrence of paradoxical reactions appears more temporally related to antiretroviral than to anti-tuberculosis therapy.


CONCLUSIONS
It is important for clinicians to recognise paradoxical tuberculous reactions as inflammatory responses to treatment, and to understand that they do not necessarily indicate drug resistance or an inadequate response to therapy. Anti-tuberculosis and antiretroviral drug regimens need not be altered or discontinued, although a short course of corticosteroids may be useful in reducing inflammation.
Orlovic
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Sizwe Tropical Diseases Hospital, University of the Witwatersrand/South African Institute for Medical Research, Johannesburg.
Smego
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RA
D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis* / Q000188:drug therapy*; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage; D000995:Antitubercular Agents / Q000008:administration & dosage*; D001707:Biopsy, Needle; D005260:Female; D005500:Follow-Up Studies; D006679:HIV Seropositivity; D006801:Humans; D008206:Lymphatic Diseases / Q000382:microbiology*; D008297:Male; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013183:Sputum / Q000382:microbiology; D016896:Treatment Outcome; D014374:Tuberculin Test; D014391:Tuberculosis, Miliary / Q000175:diagnosis* / Q000188:drug therapy*
D019380:Anti-HIV Agents; D000995:Antitubercular Agents