Paradoxical Reaction in Tuberculous Meningitis and Tuberculoma: Diagnostic Challenges Following Incomplete Treatment

Rocksy Fransisca V Situmeang — 2025-11-10

Introduction: Exacerbation of clinical or radiological findings in tuberculous meningitis (TBM) may result from a paradoxical reaction (PR), an immune-mediated response occurring in 6–30% of cases during or after anti-tuberculosis treatment (ATT). This case highlights the potential for PR to occur in the context of an incomplete ATT regimen. Case Illustration: A 20-year-old female presented with a 1-month history of headache, fever, double vision, nuchal rigidity, and bilateral abducens palsy. Cerebrospinal fluid analysis revealed pleocytosis and elevated protein, while brain MRI demonstrated leptomeningeal enhancement with multiple tuberculomas. She received standard ATT (RHZE), but discontinued therapy before completion due to symptom resolution and medication burden. One year later, she developed altered sensorium and behavioral changes; MRI showed new tuberculomas with edema despite negative serology. A diagnosis of PR was made, and high-dose intravenous corticosteroids were administered, resulting in clinical and radiological improvement. Discussion: PR remains a diagnostic challenge, often mistaken for microbiological relapse, drug resistance, or treatment failure. It arises from a distinct immune response to mycobacterial antigens, distinguishing it from relapse or drug resistance. Conclusion: Clinicians should suspect PR in worsening TBM cases, even in the setting of incomplete ATT, to prevent misdiagnosis and initiate prompt treatment.

Penatalaksanaan Gagal Napas pada Poliautoimun Multipel Sklerosis dengan Krisis Miastenia

Eva Octavia — 2025-11-07

Introduction: Polyautoimmune involving multiple sclerosis (MS) and myasthenia gravis (MG) is rare, with overlapping clinical manifestations due to shared immunopathogenic mechanisms. The main challenge in such patients is the high risk of ventilator weaning failure, especially when complicated by ventilator-associated pneumonia (VAP). This report highlights the rarely reported success of ventilator weaning through a multidisciplinary and comprehensive management approach in MS-MG polyautoimmunity. Case Illustration: A 39-year-old female with relapsing-remitting MS and MG developed a myasthenic crisis requiring mechanical ventilation. Therapeutic plasma exchange (TPE) was initiated on the second day of treatment and continued for five cycles. Ventilator weaning was performed gradually in accordance with clinical improvement, but was hindered by VAP, necessitating tracheostomy. High-protein enteral nutrition support and early mobilization were initiated on the second day of treatment. After 24 days of intensive care, the patient was successfully weaned from the ventilator with stable respiratory function and improved muscle strength. She was discharged ten days later with tracheostomy care instructions and was able to perform independent active mobilization. Discussion: MS-MG polyautoimmunity presents complex immunological mechanisms that require a multidisciplinary approach. Evidence-based comprehensive management that integrates immunomodulatory therapy, treatment of VAP complications, high-protein enteral nutrition, mobilization, and progressive pulmonary rehabilitation significantly improved respiratory function and accelerated weaning from the ventilator. Conclusion: An evidence-based, comprehensive approach through multidisciplinary collaboration can enhance ventilator weaning and improve clinical outcomes and quality of life in patients with MS-MG polyautoimmunity.

Jurnal Kedokteran Meditek

Paradoxical Reaction in Tuberculous Meningitis and Tuberculoma: Diagnostic Challenges Following Incomplete Treatment

Penatalaksanaan Gagal Napas pada Poliautoimun Multipel Sklerosis dengan Krisis Miastenia