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TB Lymph Node Paradoxical Reaction — SCE Infectious Diseases MCQ

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ModerateTuberculosisTB Lymph Node Paradoxical ReactionSCE Infectious Diseases

A 30-year-old man from East Africa presents with painless bilateral cervical lymphadenopathy. FNA shows caseating granulomata and is AFB-positive on ZN stain. He is started on standard RHZE. After 6 weeks of treatment, the lymph nodes enlarge significantly and one begins to drain spontaneously. CRP has improved and he is otherwise well. What management is appropriate?

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Correct answer: D — Expectant management — this is a paradoxical reaction; continue RHZE; aspirate the draining node if needed; corticosteroids if severe

Paradoxical reactions in TB lymphadenitis occur in approximately 25% of patients. They manifest as enlarging or new lymph nodes, development of abscesses, or sinus tract formation DURING effective anti-TB treatment. Improving inflammatory markers and clinical wellbeing indicate effective therapy. This is an immunological phenomenon (enhanced delayed-type hypersensitivity to mycobacterial antigens released by dying organisms) — not treatment failure. Management is conservative: continue TB treatment, aspirate fluctuant nodes, add corticosteroids for severe reactions. Do NOT change the regimen.

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