Paradoxical Deterioration During Treatment of Tuberculous Meningitis Responded to Infliximab But Not to Steroids

Almir Husic; Jonas Jäggi; Benjamin Müller; David Dashti; Sebastian Wirz; Eliska Potlukova; Alessandra Angelini

doi:10.12890/2024_004822

Paradoxical Deterioration During Treatment of Tuberculous Meningitis Responded to Infliximab But Not to Steroids

Eur J Case Rep Intern Med. 2024 Nov 15;11(12):004822. doi: 10.12890/2024_004822. eCollection 2024.

Authors

Almir Husic¹, Jonas Jäggi², Benjamin Müller¹, David Dashti³, Sebastian Wirz⁴, Eliska Potlukova¹, Alessandra Angelini¹

Affiliations

¹ Department of Internal Medicine, University Center of Internal Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.
² Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland.
³ Institute of Radiology and Nuclear Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.
⁴ Department of Infectious Diseases, University Center of Internal Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.

Abstract

Paradoxical deterioration in patients with tuberculous meningitis is a significant diagnostic and treatment challenge. We present the case of a 55-year-old previously healthy male, human immunodeficiency virus (HIV)-negative, presenting with headache, fever, agitation and slurred speech, who was ultimately diagnosed with tuberculous meningoencephalitis confirmed by cerebrospinal fluid polymerase chain reaction positive for Mycobacterium tuberculosis complex. After initiation of a standard antitubercular therapy combined with glucocorticoids, the patient experienced an initial neurological improvement. However, after 3 months of therapy, he had a major stroke with neurological deterioration, clinically and radiologically attributable to a paradoxical deterioration or an immune reconstruction syndrome as described in HIV-positive patients. Due to the persistence of inflammatory symptoms and radiological evidence of worsening tuberculomas despite ongoing antituberculosis therapy, off-label use of the tumour necrosis factor (TNF) inhibitor infliximab was initiated. The patient received three doses of infliximab at 5 mg/kg at monthly intervals, which led to marked clinical and radiological improvement. Follow-up magnetic resonance imaging showed regression of lesions, and the patient was eventually discharged with a significant recovery of motor and speech functions. This case underscores the potential of TNF inhibitors in managing severe cases of paradoxical deterioration in patients with tuberculous meningitis, challenging existing treatment paradigms and suggesting a need for further research into the pathophysiology and treatment of this condition.

Learning points: Patients with tuberculous meningitis may experience a paradoxical deterioration in spite of correct antituberculosis treatment.The paradoxical deterioration may have a severe clinical presentation, requiring high vigilance and consideration of treatment escalation.Here we report that off-label administration of tumour necrosis factor-alpha blocker infliximab induced a significant clinical and radiological improvement in a severe case of paradoxical deterioration in a patient with tuberculous meningitis, suggesting its potential as a treatment when standard therapies fail.

Keywords: Central nervous system tuberculosis; IRIS; immune reconstitution inflammatory syndrome; infliximab; neurological complications.