Olivier Bill 1 , Christian Chuard 2 , David Chabanel 1 ,

1. Tuberculosis Paradoxical Reaction: Hunting Tuberculosis (TB) From a Hide Olivier Bill1, Christian Chuard2, David Chabanel1, 1Internal Medicine Departement, HIB, Payerne and 2Infectiology, HFR, Fribourg, Switzerland Site de Payerne 1. Case Description A 82 y.o. patient with suspicion of adrenal insufficiency is newly diagnosed with active TB.He develops a daily fever >39°C with a peak at 7 a.m. short after the introduction of antituberculous therapy. Additional community acquired infection, nosocomial infection, tuberculoma, inadequate antituberculous treatment, poor compliance, and side effects of therapy are excluded. The patient is HIV-negative. 4. Discussion Our case is uncommon relative to the classical profile of subjects who develop a paradoxical reaction. In particular, our patient did not have neurological TB, milliary TB or pleural effusion on chest X-rays. His age and the kinetics of the reaction are not typical either. There are no data concerning the influence of adrenal insufficiency on response to anti-TB therapy. 5. Conclusion Our case seems to confirm that Tuberculosis Paradoxical Reaction is  hardly predictable in its timing, duration and severity. One should always be aware of potential paradoxical reaction when immune status is altered, especially by poor nutritional status, age, corticosteroid therapy or any other factor that decreases cell mediated immunity. More reviews are needed to get a better understanding of the profile and course of this condition. 2. Background Tuberculosis Paradoxical Reaction is defined as clinical or radiological worsening of pre-existing TB lesions or new lesions when introducing anti-TB therapy, in the absence of disease relapse or another diagnosis. It is rarely described in non-HIV patients. Fever and lymph nodes enlargement seem to be the most common manifestations. Treatement consists of surgery or corticotherapy depending on the site affected. • References: • Breen, R. A., et al. "Paradoxical reactions during tuberculosis treatment in patients with and without HIV co-infection." Thorax 59.8 (2004): 704-07. • Broekmans, J. F., et al. "European framework for tuberculosis control and elimination in countries with a low incidence. Recommendations of the World Health Organization (WHO), International Union Against Tuberculosis and Lung Disease (IUATLD) and Royal Netherlands Tuberculosis Association (KNCV) Working Group." Eur Respir J 19.4 (2002): 765-75. • Cheng, V. C., et al. "Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients." Eur J Clin Microbiol Infect Dis 21.11 (2002): 803-09. • Ligue Pulmonaire Suisse. Manuel suisse de la Tuberculose. 2007. 3. Mechanism Biological reaction to TB antigenic proteins exposed in a greater amount after anti-TB treatement initiation. This could explain why more frequent in HIV+ patients with an immune reconstitution syndrome.