Ground-glass opacity as a paradoxical reaction in miliary tuberculosis: A case report and review of the literature

Abstract

A paradoxical reaction (PR) is an excessive immune response occurring during antitubercular therapy (ATT), but is rare in patients with miliary tuberculosis. A 78-year-old woman complained of general malaise, loss of appetite, and fever for 10 days. Chest computed tomography (CT) showed diffuse, bilateral, discrete miliary nodules. The patient was treated with ATT for miliary tuberculosis. Nine days after starting the treatment, she developed a spiking fever and worsening malaise. Repeat CT showed new localized ground-glass opacity (GGO) in the right upper lobe. After excluding possible etiologies, she was diagnosed with PR due to ATT. She was successfully managed with oral prednisolone while continuing ATT. The GGO diminished and did not recur after discontinuation of the steroids. We reviewed 28 reported cases of miliary tuberculosis with a PR in patients not infected with human immunodeficiency virus. Those not on immunosuppressive therapy were likely to develop a PR early. This case illustrates that a PR may present as localized GGO in miliary tuberculosis in the lung of patients treated with ATT. In cases of a PR with marked symptoms, steroid therapy may be valuable.

Relapsing paradoxical reaction in miliary tuberculosis: a case report and literature review

“…PR is believed to occur as a result of recovery of the immune system with an enhanced inflammatory response, hence it was also termed "immune reconstitution syndrome." It has been postulated that PR results from the influx of both type 1 and 2 helper lymphocytes following the destruction of the TB bacilli, followed by release of a variety of cytokines that lead to an exaggerated immune response [5,9]. We could not find pathological description of PR in previous reports.…”

“Ground glass opacity” sign in lung diseases: nuances of radiological diagnosis and correct interpretation

“…Yu.Tokuyama et al (2019) [56] описан случай пара доксальной реакции при 4компонентной терапии (изониазид, рифампицин, этамбутол, пиразинамид) милиарного туберкулеза в виде появления участка уплотнения по типу «матового стекла» на фоне множе ственных мелких очагов в паренхиме легких (рис. 5).…”

“…5. Мультиспиральная компьютерная томография[56] органов грудой клетки, аксиальные срезы: A -множественные двусторонние милиарные узелки; B -в верхней доле правого легкого визуализируется сливной участок снижения пневматизации по типу «матового стекла» (белые стрелки) Figure5. Multislice computed tomography[56] of the chest, axial sections: A, multiple bilateral miliary nodules; B, fuzed "ground glass" area of reduced pneumatization in the upper lobe of the right lung (white arrows)…”