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□ PICTURES IN CLINICAL MEDICINE □

Late-occurring Paradoxical Reaction Masqueradingas Treatment Failure for Tuberculous Adenitis

Takeshi Saraya 1, Masae Ariga 2, Hajime Takizawa 1 and Hajime Goto 1

Key words: paradoxical reaction, tuberculous adenitis

(Intern Med 52: 2385-2386, 2013)(DOI: 10.2169/internalmedicine.52.0826)

１Department of Respiratory Medicine, Kyorin University School of Medicine, Japan and ２Department of Internal Medicine, Jiundo Naika Hospi-

tal, Japan

Received for publication April 20, 2013; Accepted for publication June 10, 2013

Correspondence to Dr. Takeshi Saraya, sara@yd5.so-net.ne.jp

Intern Med 52: 2385-2386, 2013 DOI: 10.2169/internalmedicine.52.0826

2386

A 74-year-old previously healthy woman was diagnosed

with tuberculous adenitis based on the findings of a right

cervical lymph node biopsy. Following the initiation of

antituberculous therapy [Picture A: pretreatment, Pic-

ture B and E: six months after treatment (AT), Pic-

ture C and F: eight months AT, Picture D: 12 months AT],

cervical lymphadenopathic lesions of various sizes pro-

gressed, and thereafter spontaneously regressed over a pe-

riod of two years. On cervical computed tomography, the

lymphadenopathic lesions were identified to be ring-

enhanced nodular lesions with a necrotic component. In-

deed, the lymphadenopathic lesions were found to be com-

prised of fluid with debris on needle aspiration. In addition,

the lesions were negative-culture for M. tuberculosis but

positive for acid-fast staining (Gafky No. 3) at six months

AT only (Picture B-1 and E arrow). Paradoxical reactions

are characterized by the enlargement of preexisting or new

lymph nodes and generally appear in the first three months

after treatment (1). However, a previous report (2) showed

that such reactions can occur in patients with tuberculous

adenitis both during and even at the completion of long-

term (18-month) chemotherapy without indicating a failure

of treatment or relapse, as observed in the present case.

The authors state that they have no Conflict of Interest (COI).

References

1. Hawkey CR, Yap T, Pereira J, et al. Characterization and manage-

ment of paradoxical upgrading reactions in HIV-uninfected pa-

tients with lymph node tuberculosis. Clin Infect Dis 40: 1368-

1371, 2005.

2. Short course chemotherapy for tuberculosis of lymph nodes: a

controlled trial. British Thoracic Society Research Committee. Br

Med J (Clin Res Ed) 290: 1106-1108, 1985.

Ⓒ 2013 The Japanese Society of Internal Medicine

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