https://doi.org/10.4081/monaldi.2023.2625
Paradoxical reaction in peripheral lymph node tuberculosis: a review for its prevalence, clinical characteristics, and possible treatment
Submitted: May 5, 2023
Accepted: September 27, 2023
Published: October 3, 2023
Accepted: September 27, 2023
Abstract Views: 399
PDF_early view: 217
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
The paradoxical reaction (PR) is a transient worsening following tuberculosis treatment and it is not uncommon in lymph node tuberculosis (LNTB). PR in LNTB maybe wrongly considered as treatment failure or relapse. This review was undertaken to address various aspects of PR associated with lymph node tuberculosis prevalence, underlying mechanism, clinical pattern, predictors, and possible treatment in an immunocompetent individual. A literature review was performed using various databases (PubMed, Scopus, Science Direct, and Google Scholar) to identify relevant articles for review. The prevalence of paradoxical reactions associated with LNTB varies from as low as 13.3% to as high as 35.3% PR may occur during antitubercular treatment or be reported even after completion of treatment called post-therapy PR. An onset of PR may occur within a month of therapy to even 12 months from the initiation of an anti-tubercular drug. Delayed hypersensitivity reaction and reduction in immune suppression is believed to be possible mechanism leading to a paradoxical reaction. PR in LNTB is characterized by either progression of pre-existing nodal enlargement or formation of abscess, sinus formation, or appearance of new nodal enlargement or rarely extra-nodal involvement. PR is a diagnosis of exclusion and may show granuloma, positive AFB smear, or positive GeneXpert but AFB culture is always negative. Younger age, lymph node size of equal to or more than 3 cm, female gender, unilateral lymphadenopathy, and those with positive AFB on initial examination are predictors for PR in peripheral LNTB. The majority of PR in LNTB have a mild course and are generally self-limited.
Carvalho ACC, De Iaco G, Saleri N, et al. Paradoxical reaction during tuberculosis treatment in HIV-seronegative patients. Clin Infect Dis 2006;42:893-5.
DOI: https://doi.org/10.1086/500459
Chen YM, Lee PY, Su WJ, Perng RP. Lymph node tuberculosis: 7-year experience in Veterans General Hospital, Taipei, Taiwan. Tuber Lung Dis 1992;73:368-71.
DOI: https://doi.org/10.1016/0962-8479(92)90042-I
Cho O-H, Park K-H, Kim T, et al. Paradoxical responses in non-HIV-infected patients with peripheral lymph node tuberculosis. J Infect 2009;59:56-61.
DOI: https://doi.org/10.1016/j.jinf.2009.05.006
Hawkey CR, Yap T, Pereira J, et al. Characterization and management of paradoxical upgrading reactions in HIV-uninfected patients with lymph node tuberculosis. Clin Infect Dis 2005;40:1368-71.
DOI: https://doi.org/10.1086/429317
Park K-H, Cho O-H, Chong YP, et al. Post-therapy paradoxical response in immunocompetent patients with lymph node tuberculosis. J Infect 2010;61:430-4.
DOI: https://doi.org/10.1016/j.jinf.2010.08.011
Batra S, Rajawat GS, Takhar RP, Gupta ML. Pattern and predictors of paradoxical response in patients with peripheral lymph node tuberculosis. Tuberk Toraks 2017;65:180-5.
DOI: https://doi.org/10.5578/tt.27597
Rajendra A, Sabnis K, Jeyaseelan V, Rupali P. Paradoxical reaction (PR) in tuberculous lymphadenitis among HIV-negative patients: retrospective cohort study. Postgrad Med J 2016;92:684-5.
DOI: https://doi.org/10.1136/postgradmedj-2016-134326
Chahed H, Hachicha H, Berriche A, et al. Paradoxical reaction associated with cervical lymph node tuberculosis: predictive factors and therapeutic management. Int J Infect Dis 2017;54:4-7.
DOI: https://doi.org/10.1016/j.ijid.2016.10.025
Rai DK, Kumar R, Ahmad S. Clinical characteristics and treatment outcome in Tubercular lymphadenitis patients- A prospective observational study. Indian J Tuberc 2020;67:528-33.
DOI: https://doi.org/10.1016/j.ijtb.2020.07.021
Cheng VCC, Yam WC, Woo PCY, et al. Risk factors for development of paradoxical response during antituberculosis therapy in HIV-negative patients. Eur J Clin Microbiol Infect Dis 2003;22:597-602.
DOI: https://doi.org/10.1007/s10096-003-0998-z
Choremis CB, Padiatellis C, Zou Mbou Lakis D, Yannakos D. Transitory exacerbation of fever and roentgenographic findings during treatment of tuberculosis in children. Am Rev Tuberc 1955;72:527-36.
Breen R, Smith C, Bettinson H, et al. Paradoxical reactions during tuberculosis treatment in patients with and without HIV co-infection. Thorax 2004;59:704-7.
DOI: https://doi.org/10.1136/thx.2003.019224
Belum GR, Belum VR, Chaitanya Arudra SK, Reddy BSN. The Jarisch-Herxheimer reaction: revisited. Travel Med Infect Dis 2013;11:231-7.
DOI: https://doi.org/10.1016/j.tmaid.2013.04.001
Campbell IA, Dyson AJ. Lymph node tuberculosis: a comparison of various methods of treatment. Tubercle 1977;58:171-9.
DOI: https://doi.org/10.1016/0041-3879(77)90041-1
Cheng VCC, Ho PL, Lee RA, et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur J Clin Microbiol Infect Dis 2002;21:803-9.
DOI: https://doi.org/10.1007/s10096-002-0821-2
Barr DA, Coussens AK, Irvine S, et al. Paradoxical upgrading reaction in extra-pulmonary tuberculosis: association with vitamin D therapy. Int J Tuberc Lung Dis 2017;21:677-83.
DOI: https://doi.org/10.5588/ijtld.16.0927
Wang C-S, Chen H-C, Yang C-J, et al. The impact of age on the demographic, clinical, radiographic characteristics and treatment outcomes of pulmonary tuberculosis patients in Taiwan. Infection 2008;36:335-40.
DOI: https://doi.org/10.1007/s15010-008-7199-8
Cheng S-L, Wang H-C, Yang P-C. Paradoxical response during anti-tuberculosis treatment in HIV-negative patients with pulmonary tuberculosis. Int J Tuberc Lung Dis 2007;11:1290-5.
Bhattacharya A, Mukherjee S. Paradoxical reaction in the form of pleural effusion after onset of anti-tuberculous medication for tubercular lymphadenitis. Clin Med (Lond) 2017;17:143-5.
DOI: https://doi.org/10.7861/clinmedicine.17-2-143
Thorve SM, Patil NS, Mandilwar S, Vora A. Loss of vision and hearing in a case of cervical lymph node tuberculosis: A rare paradoxical reaction. Lung India 2017;34:573-5.
DOI: https://doi.org/10.4103/lungindia.lungindia_231_17
Takahashi S, Otomo K, Kawakami Y, Nakamura M. Uveitis developing in tuberculous lymphadenitis-associated Behçet’s disease during anti-tuberculosis therapy. Respirol Case Rep 2020;8:e00617.
DOI: https://doi.org/10.1002/rcr2.617
Lakshmi VP, Abhinandh B, Kunoor A, et al. Paradoxical reaction in lymph node tuberculosis presented as shoulder osteomyelitis. J Pharmacol Pharmacother 2021;12:140-3.
DOI: https://doi.org/10.4103/jpp.jpp_61_21
Brown CS, Smith CJ, Breen RAM, et al. Determinants of treatment-related paradoxical reactions during anti-tuberculosis therapy: a case control study. BMC Infect Dis 2016;16:479.
DOI: https://doi.org/10.1186/s12879-016-1816-4
Polesky A, Grove W, Bhatia G. Peripheral tuberculous lymphadenitis: epidemiology, diagnosis, treatment, and outcome. Medicine (Baltimore) 2005;84:350-62.
DOI: https://doi.org/10.1097/01.md.0000189090.52626.7a
World Health Organization Country Office for India. Index-TB guidelines: guidelines on extra-pulmonary tuberculosis in India. 2016. Available from: https://iris.who.int/handle/10665/278953
Bunkar ML, Agnihotri SP, Gupta PR, Arya S. Add-on prednisolone in the management of cervical lymph node tuberculosis. Indian J Tuberc 2016;63:96-9.
DOI: https://doi.org/10.1016/j.ijtb.2015.05.002
Geri G, Passeron A, Heym B, et al. Paradoxical reactions during treatment of tuberculosis with extrapulmonary manifestations in HIV-negative patients. Infection 2013;41:537-43.
DOI: https://doi.org/10.1007/s15010-012-0376-9
Jung JW, Shin JW, Kim JY, et al. Risk factors for development of paradoxical response during anti-tuberculosis treatment in HIV-negative patients with pleural tuberculosis. Tohoku J Exp Med 2011;223:199-204.
DOI: https://doi.org/10.1620/tjem.223.199
Rakotoson JL, Rakotomizao JR, Andrianasolo RL, et al. [Paradoxical lymphadenopathy during treatment of cavitary tuberculosis in an immunocompetent patient].[Article in French]. Rev Pneumol Clin 2011;67:318-21.
DOI: https://doi.org/10.1016/j.pneumo.2010.11.006
Banani SA, Alborzi A. Needle aspiration for suppurative post-BCG adenitis. Arch Dis Child 1994;71:446-7.
DOI: https://doi.org/10.1136/adc.71.5.446
Meybeck A, Just N, Nyunga M, et al. [Needle aspiration in paradoxical hypertrophy of tuberculous lymphadenitis].[Article in French]. Rev Mal Respir 2003;20:973-7.
Blackmore TK, Manning L, Taylor WJ, Wallis RS. Therapeutic use of infliximab in tuberculosis to control severe paradoxical reaction of the brain and lymph nodes. Clin Infect Dis 2008;47:e83-5.
DOI: https://doi.org/10.1086/592695
How to Cite
Rai, Deependra Kumar, Surya Kant, and Vatsal Bhushan Gupta. 2023. “Paradoxical Reaction in Peripheral Lymph Node Tuberculosis: A Review for Its Prevalence, Clinical Characteristics, and Possible Treatment”. Monaldi Archives for Chest Disease, October. https://doi.org/10.4081/monaldi.2023.2625.
Copyright (c) 2023 The Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
