Paradoxical reactions in central nervous system tuberculosis: Insights into pathogenesis, diagnosis, and clinical management

Paradoxical reactions are immune-mediated complications that can arise during the treatment of tuberculosis, particularly in central nervous system tuberculosis. These reactions are characterised by clinical or radiological deterioration in patients who are already receiving appropriate anti-tuberculous therapy, driven by an exaggerated immune response to residual mycobacterial antigens. Central nervous system tuberculosis, one of the most severe forms of extrapulmonary tuberculosis, presents a significant therapeutic challenge when complicated by paradoxical reactions. This review explores the underlying mechanisms of these reactions, the diagnostic challenges faced by clinicians, and current therapeutic approaches, including the use of corticosteroids, tumour necrosis factor-alpha (TNF-α) antagonists, and surgical interventions, while also addressing gaps in existing knowledge and practice.