Professional Documents
Culture Documents
Management of Paradoxical Response in Pediatric Tubercular Meningitis With Methylprednisolone
Management of Paradoxical Response in Pediatric Tubercular Meningitis With Methylprednisolone
168]
Case Report
Departments of Ophthalmology, 1Pediatrics, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India
Corresponding Author: Dr. Nitin Nema, Department of Ophthalmology, SAIMS, 55 Shri Nagar Main, Indore ‑ 452 018, Madhya Pradesh, India.
E‑mail: nemanitin@yahoo.com
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014 189
[Downloaded free from http://www.meajo.org on Wednesday, January 9, 2019, IP: 112.215.151.168]
paradoxical tuberculous OCA was made on the basis of MRI ophthalmoscopic examination showed a normal fundus.
findings, cerebrospinal fluid (CSF) analysis (cells 910/cu mm, Six days postoperatively, the child was referred back to us by
protein 230 mg/dL, glucose 30 mg/dL, Pandy test positive), the pediatric surgeon with complaints of bilateral loss of vision.
and clinical findings. Under cover of ATT, intravenous The child was on 4‑drug ATT (isoniazid 5 mg/kg/day, rifampicin
methylprednisolone (IVMP), 30 mg/kg body weight/day, was 10 mg/kg/day, pyrazinamide 25 mg/kg/day and ethambutol
administered. After three doses the visual acuity increased 15 mg/kg/day) but not on systemic steroids. The visual acuity
to light perception in both eyes. IVMP was continued for at this visit was no fixation or following of light. There was no
two more days and then the medication was changed to oral light perception in both eyes with absence of pupillary reaction
prednisolone tablets (2 mg/kg body weight/day in single to light. Fundus examination by indirect ophthalmoscope
dose) on a tapering schedule for a month. The vision slowly and 78 D slit‑lamp ophthalmoscopy showed normal fundi
improved over a period of 12 weeks. Seven months after bilaterally. Brain MRI showed enhancing lesions at the level
the visual loss, brain MRI showed decreased inflammation of optic chiasm involving both the optic nerves. A diagnosis
of the meningeal sheaths around the optic nerves and mild of paradoxical OCA was made on the basis of the clinical
hydrocephalus [Figure 2]. ATT was stopped after 12 months. picture, CSF analysis (cells 120/cu mm, 90% lymphocytes,
At the 18 months follow‑up visit, the best corrected vision protein 20 mg/dL) and neuroimaging findings. The child was
was 6/18 in right eye and 6/12 in the left. The pupils in both started on 30 mg/kg body weight IVMP for five days and then
eyes were approximately 4 mm in diameter round and briskly placed on systemic prednisolone (2 mg/kg body weight/day)
reactive to torch light. Fundus examination showed optic disc on tapering dose along with systemic ATT. Two weeks after
pallor bilaterally [Figure 3]. starting systemic corticosteroids, the child started to perceive
light on vision testing. ATT was stopped after a year and the
Case 2
best corrected visual acuity at that time was 6/18 in both eyes.
A four‑year‑old male child, fully immunized and his vaccinations
The pupils were round, semi‑dilated with brisk reaction to light.
were current, had stage I TBM with hydrocephalus, was
Fundus examination showed prominent temporal pallor of the
on oral ATT for three weeks. He underwent surgery for
ventriculoperitoneal shunt (VP shunt) under general optic nerve head in both eyes [Figure 4]. Magnetic resonance
anesthesia after his systemic condition stabilized. Preoperative imaging of the brain showed VP shunt in situ with no evidence
of exudate in the optochiasmatic region.
a b a b
Figure 3: a and b. Diffuse bilateral optic disc pallor Figure 4: Optic discs of right (a) and left (b) eyes showing pallor
190 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014
[Downloaded free from http://www.meajo.org on Wednesday, January 9, 2019, IP: 112.215.151.168]
DISCUSSION ATT. The rationale behind the use of adjuvant steroids lies in
reducing the harmful effects of inflammation as anti‑tubercular
Tuberculosis is a common cause of morbidity and mortality in drugs kill the organisms.9 Treatment with corticosteroids
developing countries such as India. TBM is the most serious decreases the basal exudates and stabilizes vision, and in some
form of TB in children below five years of age.2,3 There is cases improves vision.6
preponderance of the disease in male children.4,5
In this case report, the two children were responding well to
OCA refers to inflammatory changes with exudates in the ATT when they noticed profound vision loss. The first child was
leptomeninges around the optic chiasm and the optic nerve.6 receiving systemic steroid on a tapering dose while the second
Tuberculosis is endemic in India, hence, OCA can occur during child was on ATT only. Both cases were small male children with
the course of treatment for TBM or following withdrawal high protein content and cell count in the CSF who developed
of systemic steroids.6,9 OCA is the leading cause of visual paradoxical OCA. They responded well to intensive high‑dose
impairment in TBM.6,10 Early recognition of this condition and intravenous methylprednisolone and systemic corticosteroids
appropriate treatment can prevent further visual loss and, at with reasonably good final visual acuity.
least, salvage some functional vision.6
CONCLUSION
A reliable method of establishing the diagnosis of OCA includes
visual complaints, abnormal pupillary reactions to light, dilated Ophthalmologists and pediatricians should be aware of the
fundus examination with special attention on the examination of paradoxical response to ATT. One must predict OCA in children
optic nerve head and contrast‑enhanced MRI. Dense plaque‑like suffering from TBM who present with severe visual loss without
basal exudates especially around the optic chiasm are seen on systemic deterioration and with high CSF protein and pleocytosis
MRI that show enhancement and hypertrophy of the chiasm and perichiasmal exudates on MRI. Prompt treatment with
and proximal optic nerves.11 These features may be associated IVMP followed by oral steroid may salvage vision in these
with hydrocephalus.6 children.
Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014 191
[Downloaded free from http://www.meajo.org on Wednesday, January 9, 2019, IP: 112.215.151.168]
patients with CNS tuberculosis. J Assoc Physicians India meningitis. Acta Neurol Scand 1980;62:368‑81.
2003;51:257‑60. 16. Schoeman JF, Andronikou S, Stefan DC, Freeman N, van
13. Zaki SA, Shenoy P. Paradoxical response to anti‑tubercular Toom R. Tuberculous meningitis‑related optic neuritis:
treatment. Indian J Pharmacol 2011;43:212‑3. Recovery of vision with thalidomide in 4 consecutive cases.
14. G o u r i e ‑ D e v i M . O p t o c h i a s m a t i c a r a c h n o i d i t i s a n d J Child Neurol 2010;25:822‑8.
neurotuberculosis. Prognostic indicators and therapeutic
strategies. Neurol India 2010;58:714‑5. Cite this article as: Nema N, Verma A, Singh K, Mehar V. Management of
paradoxical response in pediatric tubercular meningitis with methylprednisolone.
15. Gourie‑Devi M, Satish P. Hyaluronidase as an adjuvant in
Middle East Afr J Ophthalmol 2014;21:189-92.
the treatment of cranial arachnoiditis (Hydrocephalus and
Source of Support: Nil, Conflict of Interest: None declared.
optochiasmatic arachnoiditis) complicating tuberculous
192 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014