Tuberculous Meningitis With Paradoxical Reaction in an Immunocompetent Young Male Treated by Interleukin‐1 Receptor Antagonist

A 22-year-old man presented with headache, night sweats, intermittent fever, tremors, sleep disturbances, agitation, and hallucinations for 2 months. Thoracic computed tomography (CT) showed widespread interstitial nodular lesions, but initial cranial CT showed no significant pathology. Cerebrospinal fluid (CSF) analysis revealed 25 cells/mm³ of white blood cells (72% neutrophils), 83 mg/dL protein, and 30 mg/dL glucose (concurrent serum glucose was 103 mg/dL). Gram and Ziehl-Neelsen stains were negative for acid-fast bacilli. Tuberculosis (TB) cultures and Mycobacterium PCR tests remained negative. Biopsy of the bronchoalveolar lavage sample showed necrotizing granulomatous inflammation, and the <i>Mycobacterium tuberculosis</i> PCR result was positive. During the first month of first-line anti-TB treatment, the patient experienced recurrent severe headaches, persistent fever, and decreased visual acuity. Contrast-enhanced MRI revealed lesions that were consistent with tuberculous meningitis (TBM). Considering the possibility of drug-resistant TB, streptomycin 1 gr/qd (quaque die) intramuscularly and linezolid 600 mg/bid (bid in die) intravenously were added to the regimen. The patient's symptoms persisted during the second month of treatment. The patient experienced epileptic seizures. The control MRI showed an enlargement of the lesions. A paradoxical reaction was considered. Intravenous methylprednisolone 500 mg/day was initiated. The patient did not respond clinically, and his complaints continued. The patient was started on the IL-1 inhibitor anakinra. Paradoxical inflammatory reactions are common in TBM but challenging to predict. When severe, they can lead to significant neurological morbidity and death. This article aimed to share a case that did not respond to corticosteroids, a standard treatment for paradoxical reactions, but was successfully managed with the IL-1 inhibitor anakinra.