PROF .DR.J.SANGUMANI M.D.,D.Diab A TUBERCULAR PARADOX V MU PROF .DR.J.SANGUMANI M.D.,D.Diab DR.R.SUNDARAM M.D., DR.K.S.RAGHAVAN M.D.,D.Diab.,

13 yrs old female child presented with new onset seizure – twitching of facial muscles followed by GTCS -3 episodes lasting 10 mins -regaining consciousness after each episode No H/0 fever No H/0 altered sensorium No H/0 head injury No H/0 diarrhea/vomitting

No H/0 headache No H/0 blurring of vision No H/0 weakness of limbs No H/o diplopia No H/0 sensory disturbances No H/o chronic cough with expectoration No H/o ear discharge

PAST HISTORY k/c congenital heart block on implanted permanent pacemaker h/o admission for fever with Multiple cervical Lymph nodes (largest 2*1.5cm) 3 months back biopsy - granulomatous lymphadenitis Patient was started on CAT-I Anti tuberculous drugs Patient on regular CAT-I ATT for past 3 months Not a k/c diabetes, asthma, thyroid disorder

Family history Mother had sputum positive pulmonary TB 6yrs back She completed ATT

GENERAL EXAMINATION Pt conscious Oriented No pallor No icterus No cyanosis No clubbing No pedal edema Cervical lymphadenopathy multiple tiny nodes <0.5cm

vitals Pulse rate – 76/min regular rhythm ,normal volume, felt in all peripheral vessels, no RRD or RF delay BP – 110/70mmhg in Right upper limb in supine posture Spo2 – 98% RR – 20 /MIN

CNS Cranial nerves normal Higher functions normal No motor or sensory deficit No cerebellar signs No neck stiffness Fundus – no papillodema or choroid tubercles

CVS – S1 S2 + no murmur RS – BAE + no added sounds Abdomen – soft no organomegaly

TREATMENT GIVEN Inj.lorazepam 2mg iv stat Inj.phenytoin 800mg iv over 30 mins then 100mg iv tds T.Pyridoxine 100mg 1 od

Blood investigations HB, Total count,differential count -normal RBS, RFT,LFT – NORMAL CXR – PACEMAKER SEEN ,no other abnormality Echo – pacemaker lead in position VVI pacing EF – 45% VCTC – not reactive

CT BRAIN contrast

Report Well defined ring enhancing lesion in right thalamus,left high parietal region,right caudate,left occipital lobe Suggestive of multiple tuberculomas

DIAGNOSIS Paradoxical reaction to ATT in form of tuberculoma

Treatment Patient was started on Inj.dexamethsone 8mg iv bd - 1 week Then at discharge T.Prednisolone 5mg 8od -2 weeks Then gradually tapered CT brain repeated at 8 th week showed reduction in size of tuberculoma

immune reconstitution syndrome A rare cause of seizure in a patient on ATT