A 35-year-old woman from Afghanistan with prior tuberculosis (TB) meningitis and Pott's disease, presented with two weeks of worsening headache and confusion. The headaches were associated with tinnitus and photophobia. Magnetic resonance (MR) imaging showed multiple rim-enhancing lesions (Figs. 1 and 2). The patient was started on isoniazid, rifampin, levofloxacin, pyridoxine, and dexamethasone with clinical deterioration. She was diagnosed with a paradoxical TB reaction, which is defined by worsening or new lesions after starting antituberculous treatment. This may be a result of an excessive inflammatory response set off by the dying mycobacteria.[1] Infliximab was added to her regimen in addition to increasing the dexamethasone dose, which led to resolution in symptoms.

Figure 1
figure 1

MR imaging in the coronal plane showing ring-enhancing lesions (blue arrows).

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Figure 2
figure 2

MR imaging in the axial plane showing ring-enhancing lesions (blue arrows).

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Mycobacteria tuberculosis is primarily a respiratory pathogen, and extrapulmonary CNS tuberculosis is uncommon, representing  ~ 4.5% of TB cases[2] and has poor outcomes with high mortality. Clinical or radiologic worsening after initiation of therapy should prompt consideration of paradoxical TB reaction. Early recognition and treatment with immunosuppressive therapy, such as corticosteroids and anti-TNF therapy, have resulted in improved outcomes by diminishing the disproportionate immune response. More investigation is needed to clarify the ideal treatment regimen to prevent paradoxical TB reactions.