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TB Paradoxical Reaction — SCE Infectious Diseases MCQ

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ModerateTuberculosisTB Paradoxical ReactionSCE Infectious Diseases

A 55-year-old woman with TB lymphadenitis has been on standard RHZE for 6 weeks. Her cervical lymph nodes have paradoxically enlarged despite good adherence and drug-sensitive TB. She is afebrile with improving inflammatory markers. What is the most likely explanation?

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Correct answer: B — Paradoxical upgrading reaction (type 1 immune reconstitution to TB antigens)

Paradoxical reactions during TB treatment occur in approximately 25% of lymph node TB cases. They manifest as enlarging or new lymph nodes, sinus formation, or constitutional symptoms during effective therapy. They result from reconstitution of cell-mediated immunity against mycobacterial antigens (analogous to IRIS in HIV). Improving inflammatory markers and continued sensitivity confirm effective treatment. Management is expectant; corticosteroids or aspiration may be needed for severe reactions.

Reference: NICE NG33 2016 – TB; BTS 2024 – Paradoxical reactions in TB