Table 1.

Tuberculous Meningitis Cases With Paradoxical Reactions Treated With Infliximab

Case	Diagnosis at Presentation	Site of Paradoxical Reaction	TB Treatment Regimen	Other Treatment Before and After Infliximab	Infliximab Dose	Outcome
Case 1: Flinders Hospital, Adelaide, 36 y, male HIV uninfected, Indiaa	Miliary TB with TBM	Multiple brain tuberculomas and obstructed CSF flow with raised ICP	Empiric HRZE, thenc   high-dose mfx, amk, lzdd, pto, Z, bdq, cfz	Before: High-dose steroidsb for 3 mo After: High-dose steroids for 4 mo; tapered over 2 mo	10 mg/kg monthly x3	Rapid fever resolution with CRP decline; improved sensorium allowing weaning off the ventilator within days; long term—mild cognitive deficit, require assistance with activities of daily living
Case 2: Concord Hospital, Sydney, 32 y, female HIV uninfected, Chinaa	Miliary TB with TBM	Multiple spinal tuberculomas with edema and local mass effect	Empiric HRZE, thene   RZE + mfx	Before: High-dose steroids for 2 mo; decompressive spinal surgery After: High-dose steroids for 2 mo; tapered over 1 mo	5 mg/kg 0, 2, 6, and 14 wk	Rapid restoration of bladder function (2 wk) and mobility (3–4 wk); long term—full neurological recovery
Case 3: Royal North Shore Hospital, Sydney, 55 y, female HIV uninfected, Indonesiaa	TBM and necrotic lymph-adenitis	Multiple brain and spinal cord tuberculomas with cauda equina syndrome	HRZ + mfx	Before: High-dose steroids for 2 mo After: High-dose steroids for 4 mo; tapered over 2 mo; failed trial of thalidomide	5 mg/kg monthly x3	Rapid resolution of fever and meningism; improvement in lower limb power; long term—incomplete recovery with compromised sphincter function at discharge; regained mobility with ongoing improvement in lower limb power
Case 4: Westmead Hospital, Sydney, 26 y, male HIV uninfected, Indiaa	PTB with CNS and bone involvement	Multiple brain and spinal tuberculomas with raised ICP, compressive spinal myelopathy, and cold abscesses	Empiric HRZE, then HR (900 mg) Z + lfx	Before: High-dose steroids for 6 wk with unsuccessful weaning After: High-dose steroids for 2 mo; tapered over 1 mo	10 mg/kg (0, 3 wk) 5 mg/kg (7, 17 wk)	Rapid resolution of fever and neurological improvement (reduced pressure effects); long term—regained sphincter function and mobility with ongoing improvement on rehabilitation

Abbreviations: amk, amikacin; bdq, edaquiline; cfz, clofazimine; CNS, central nervous system; E, ethambutol; H, isoniazid; ICP, intracranial pressure; lfx, levofloxacin; lzd, linezolid; mfx, moxifloxacin; PTB, pulmonary TB; pto, prothionamide; R, rifampicin; TB, tuberculosis; TBM, TB meningitis; Z, pyrazinamide.

^aCountry of origin.

^bHigh-dose steroids included intravenous dexamethasone (4–8 mg 3–4x/d) and/or oral prednisone (1–2 mg/kg/d - maximum 60 mg/d).

^cAfter identification of pan-resistance to all first-line drugs, including high-level isoniazid and low-level moxifloxacin resistance.

^dLinezolid (6 months) and amikacin (12 months) stopped after demonstrated toxicity.

^eIsoniazid replaced by moxifloxacin given high-level isoniazid monoresistance.