Central nervous system tuberculosis (CNS-TB) is associated with high morbidity and mortality. Paradoxical reactions (PR), defined as worsening of clinical or radiological findings due to an overshooting immune response, can occur upon initiation of appropriate antimycobacterial therapy (AMT) and lead to serious complications. They are generally more frequently seen in females and patients with HIV coinfection as part of the so-called immune reconstitution inflammatory syndrome (IRIS). Here, we describe a rare case PR in an immunocompetent male that presented as dysautonomia.

A previously healthy 29-year-old Chinese man presented with 8 days of fever and malaise and 3 days of confusion and headache. On admission, patient was severely encephalopathic with clinical signs of meningitis.  Lumbar puncture revealed elevated opening pressure (55 cmH2O), CSF protein (159 mg/dL) and nucleated cell count (543/uL) with lymphocyte predominance along with low glucose (18 mg/dL).  Imaging studies were consistent with basilar-predominant meningitis and showed multifocal likely vasculitic strokes. Pan-sensitive mycobacterium tuberculosis was confirmed by PCR testing, and AMT and a steroid taper were initiated. HIV test was negative. The patient was discharged with no residual neurological symptoms and remained on AMT. 10 weeks later, the patient was re-admitted after a witnessed syncope. Repeat MRI showed progression of basal leptomeningeal enhancement along with multiple new ring-enhancing collections consistent with tuberculomas, predominantly in basal brain regions involving the hypothalamus. Cardiac workup was normal. Electroencephalography showed no epileptiform changes. Serial vital sign assessments showed both orthostatic and spontaneous hypotension, as well as bradycardia, consistent with autonomic dysregulation. He was continued on AMT and steroid taper was re-initiated.

This is a unusual case of CNS-TB-PR leading to severe dysautonomia due to development of tuberculomas with hypothalamic involvement. Although rare, it is important to ensure close monitoring and follow-up in anticipation of possible serious complications.