Predictors of paradoxical tuberculoma in tuberculous meningitis

SETTING: A tertiary care teaching hospital in Lucknow, India. OBJECTIVE: To evaluate the frequency and predictors of paradoxical tuberculoma in definite tuberculous meningitis (TBM) and its influence on TBM outcome. DESIGN: Demographic, clinical, biochemical, cerebrospinal fluid (CSF) findings, CD4 counts and magnetic resonance imaging (MRI) findings of 34 patients with definite TBM included were noted. The patients received four-drug anti-tuberculosis treatment and prednisolone. They were followed up clinically and radiologically at 3 and 6 months; serum chemistry, CD4 counts and CSF were tested at 3 months. Functional outcome was defined on the basis of the Barthel index score. Predictors of paradoxical response were evaluated using univariate and multivariate analysis. RESULTS: The median age of the patients was 33.5 years; 13 were females. Of the 34 study participants, 22 patients developed paradoxical tuberculoma, mostly within 3 months of initiating anti-tuberculosis treatment. Paradoxical tuberculoma was associated with clinical deterioration in 12 patients. Bacille Calmette-Guerin vaccination, higher CSF glucose and abnormal baseline MRI were associated with paradoxical tuberculoma in univariate analysis. After adjustment of covariates, only female sex was independently associated with paradoxical tuberculoma (OR 0.06, 95%CI 0.004-0.79, P = 0.03). Paradoxical response, however, did not influence 6-month outcome. CONCLUSION: Paradoxical tuberculoma occurs in two thirds of patients with definite TBM, and in 50% it is asymptomatic. Females are more susceptible to paradoxical tuberculoma; however, 6-month outcome is not influenced by paradoxical tuberculoma.