Tuberculoma development in tuberculosis immune reconstitution inflammatory syndrome in an infant

A 14-month-old girl presented to the emergency department (ED) with two weeks of fever, vomiting, and new onset focal and generalized seizures and was diagnosed with tuberculosis (TB) meningitis based on imaging and serum studies, later confirmed by a TB-specific culture of the cerebral spinal fluid (CSF, acid-fast bacilli culture). She was started on anti-TB combination therapy (rifampin, isoniazid, pyrazinamide, and levofloxacin). One month later she returned to the ED with 10 days of fussiness, beginning after receiving scheduled vaccinations. Neuroimaging revealed intraparenchymal and leptomeningeal tuberculomas surrounding the anterior and posterior circulation (middle panel), which were absent from prior imaging (left panel). Repeat CSF cultures were negative for TB or other infections, leading to a diagnosis of paradoxical TB immune reconstitution inflammatory syndrome (TB-IRIS). She was started on steroids, and tuberculomas resolved within six months (right panel). She has remained seizure-free but has persistent delays in communication. Paradoxical TB-IRIS is a severe immune response that causes clinical worsening of TB lesions following initiation of appropriate treatment.1 Though rare, neurological symptoms from TB-IRIS develop at a median of 60 days after treatment.1, 2 Imaging classically demonstrates tuberculomas and/or meningitis. Patients are at a high risk of stroke given the tendency to develop lesions within the basal cisterns. Young children may be at higher risk of complications because their symptoms are often nonspecific (e.g., fussiness), leading to a delay in diagnosis (Figure 1). Alexandria E. Melendez-Zaidi: Conceptualization; writing—original draft; writing—review and editing. Fábio A. Nascimento: Writing—review and editing. Nikita M. Shukla: Resources; writing—review and editing. Thierry A. G. M. Huisman: Resources; supervision; writing—original draft; writing—review and editing. All authors accept responsibility for conduct of the research. The authors declare no conflicts of interest.