Complications
Also known as a paradoxical response. This syndrome involves transient worsening of TB symptoms and lesions despite TB treatment, and is often observed among HIV-infected TB patients soon after initiation of antiretroviral therapy. Paradoxical responses may also be seen in up to 23% of HIV-negative patients with TB lymphadenitis and presents with worsening of existing lesions or appearance of new lymphadenopathies while on TB therapy. It occurs most frequently 1 to 2 months after therapy initiation and lasts up to 2 months. Drainage may occur.[113]
Up to 20% to 30% of HIV-infected TB patients may develop immune reconstitution inflammatory syndrome (IRIS) after initiation of antiretroviral therapy (ART). IRIS appears to be more common in EPTB. Studies support initiation of ART during the intensive phase of TB therapy to improve survival.[114][115]
Manifestations may include reappearance of fever, worsening of chest x-ray results, lymphadenopathy, or an increase in pleural effusions.
It is a diagnosis of exclusion and must rule out other aetiologies, such as Pneumocystis jiroveci pneumonia. Does not appear to impact mortality unless IRIS affects the central nervous system.[113][116][117][118]
Paradoxical responses are transient and antituberculous or ART does not need to be discontinued. Paradoxical worsening in TB lymphadenitis may require prolongation of the treatment course. Repeat culture can be performed to rule out development of drug-resistant TB or concomitant pathology.
Non-steroidal anti-inflammatory drugs may provide relief. If there are significant symptoms, corticosteroids may be considered (e.g., prednisolone 1 to 2 mg/kg once daily for a few weeks then tapered gradually over several weeks) while maintaining antituberculous and ART. For painful or draining lesions, surgical excision may be considered.
Paraspinal abscess can be seen in vertebral TB (Pott's disease), occurring in 90% of cases. Abscess may extend anteriorly to ligaments or posteriorly to the epidural space. A severe complication is spinal cord compression by an adjacent abscess, sequestrum formation or direct invasion that may cause paraplegia.
Surgical therapy may be indicated if the patient has neurological deficits or progression while on medical therapy.
Disabling neurological deficits may occur in 10% to 30% of TB meningitis survivors.[101][119]
Seen in disseminated TB due to primary infection.[120]
Rarely seen in primary TB pleuritis; usual presentation is in the setting of extensive parenchymal disease. Chest tube (tube thoracostomy) is required. May require surgical intervention.
How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.
Relapse occurs when a patient becomes and remains culture-negative while on therapy, but at some point after completion becomes culture-positive again or develops clinical syndrome consistent with active TB. In the US this is generally due to recrudescence of the original organism, whereas in TB-endemic countries it may be due to exogenous reinfection. Most relapse events occur in the first 6 to 12 months following completion of treatment and in 2% to 5% of appropriately treated patients.[123][124]
If patients initially had drug-susceptible isolates and treatment was directly observed, relapse is likely due to the original susceptible organisms and prior therapy can be used. However, if the patient received self-administered therapy, there is a higher possibility of resistant organism. In this situation, or if drug susceptibility was not previously performed, an expanded regimen can be used while culture and susceptibility results are pending.
If exogenous reinfection is suspected, treatment ought to be based on the drug susceptibility profile of the index case.
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