Paradoxical reactions in tuberculous meningitis complicated with Signs of  Cushing’s Syndrome. A case report and literature review

Background: In 2022, African nations accounted for a quarter of all reported tuberculosis (TB) cases worldwide. This case report examines the diagnosis, treatment, drug toxicity, and patient management of tuberculous meningitis (TBM) in low-income country settings. Case presentation: A 34-year-old married Ethiopian woman, Gravida I and Para 0, presented to Private Hospital in Addis Ababa on May 5, 2022, with a two-day history of left-sided limb weakness, incontinence, fever, headache, vomiting, photophobia, and confusion. She had no history of contact with known pulmonary TB patients. On physical examination, she appeared acutely ill and was disoriented to time, place, and person. Laboratory findings revealed persistently elevated lymphocytes, platelets, and erythrocyte sedimentation rate (ESR). Cerebrospinal fluid (CSF) analysis showed low glucose (0.3 g/L) and elevated protein, but no acid-fast bacilli (AFB) were detected. The chest X-ray was unremarkable, but brain MRI revealed ring-enhancing lesions in the basal and suprasellar cisterns, suggestive of tuberculous (TB) granuloma. The patient was treated with first-line anti-tuberculosis treatment (ATT) regimen with adjuvant steroids for eight weeks and pyridoxine throughout the full course of treatment. During follow-up visits, the patient initially showed improvements in neurological symptoms but experienced a recurrence and worsening of the initial signs and symptoms on the ninth month of follow-up. Her physical examination was suggestive of signs of Cushing’s Syndrome. And, the control MRI was suggestive of hydrocephalus due to paradoxical reactions requiring placement of a ventriculoperitoneal shunt (VPS). The patient died on April 26, 2024. Conclusions: This case presents the challenges of diagnosis and treatment of paradoxical reactions complicated by signs of Cushing’s Syndrome secondary to TBM. In resource-limited countries, investigating brain imaging was an ideal diagnostic tool to identify underlying brain lesions. However, isolation of MTB is the only confirmatory diagnosis, and all the cytokines and other markers can only be supportive of prognostic biomarkers and cannot be confirmatory even if used in various combinations. The case managers denied the patient to receive high dose corticosteroid therapy during the continuation phase of her ATT.