Infliximab to Treat Severe Paradoxical Reaction in HIV-Negative Tuberculous Meningoencephalitis

Tuberculous meningoencephalitis was diagnosed in a 33-year-old HIV-negative patient. CSF culture was positive for drug-susceptible Mycobacterium tuberculosis and antituberculous therapy associated with steroids was started. After 3 months, brain MRI showed a worsening of the basal meningeal enhancement and the patient complained of new headaches. CSF analysis demonstrated pleocytosis (100 cells/mm³), with an increased protein count (2,580 mg/dL); CSF culture and viral panel were negative. The worsening was considered due to immune reconstitution inflammatory syndrome and infliximab was started^1,2, leading to dramatic clinical and imaging improvement (Figure).

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