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Images in Neurology |

Paradoxical Worsening of Brain Tuberculomas During Treatment

Marco A. Lima, MD, PhD; Péricles Maranhão-Filho, MD, PhD; Jane Dobbin, MD; Alexandre Gustavo Apa, MD; Gabriela A. Lima, MD; Eduardo Velasco, MD, PhD; Clemax Couto Sant′Anna, MD
Arch Neurol. 2012;69(1):138-139. doi:10.1001/archneurol.2011.720.
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An 8-year-old boy being treated with chemotherapy owing to stage IIIA Hodgkin disease was admitted to the pediatric intensive care unit because of fever and respiratory distress in the previous 2 weeks. Despite full antibiotic coverage, his condition worsened, and 7 days later, he underwent a lung biopsy. On the next day, he developed headache, vomiting, and progressive coma. A brain magnetic resonance image showed multiple small, round T2-weighted and fluid-attenuated inversion recovery hyperintense lesions (Figure, A) suggestive of brain tuberculomas. A lumbar puncture revealed a white blood cell count of 10 cells/mm3, protein level of 40 mg/dL, and glucose level of 37 mg/dL. Stains and culture results for bacteria, mycobacteria, and fungi were negative as well as cerebrospinal fluid Mycobacterium tuberculosis polymerase chain reaction. Tuberculosis was diagnosed from the lung biopsy specimen and the patient gradually improved after starting treatment with rifampicin, ethambutol hydrochloride, streptomycin, and pyrazinamide.

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Figure. Axial fluid-attenuated inversion recovery magnetic resonance imaging sequences. A, Multiple brain tuberculomas at the time of diagnosis. B, One month after treatment, there was enlargement of the lesions, worsening of the surrounding edema, and the development of new lesions. C, Five months later, a new scan showed disappearance of the lesions.

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