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Images in Neurology
Jan 2012

Paradoxical Worsening of Brain Tuberculomas During Treatment

Author Affiliations

Author Affiliations: Departments of Neurosurgery (Drs M. A. Lima and Maranhão-Filho), Hematology (Drs Dobbin and Apa), Radiology (Dr G. A. Lima), and Infectious Diseases, National Institute of Cancer (Dr Velasco), and Department of Pediatrics, Federal University of Rio de Janeiro (Dr Sant′Anna), Rio de Janeiro, Brazil.

Arch Neurol. 2012;69(1):138-139. doi:10.1001/archneurol.2011.720

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.