A 63-year-old man with
chronic myelomonocytic leukemia was admitted to our hospital with
miliary tuberculosis. He received
anti-tuberculosis drugs:
isoniazid (INH),
rifampicin (RFP),
ethambutol (EB), and
pyrazinamide (PZA). His condition clearly and immediately improved after the
therapy, but he experienced a high
fever of about 38°C every day from 1 month after the initiation of the
therapy.
Drug-induced fever and
tumor fever were suspected as causes, but the etiology could not be determined. The
tuberculosis was identified as an INH-resistant strain, so INH was stopped and
levofloxacin (LVFX) was introduced, with
streptomycin (SM), in addition to RFP, EB, and PZA. At 2 months after the initiation of the
therapy (about one week after the change in the
anti-tuberculosis drug regimen), his spinal fluid was examined, given his complaints of
headache and
vomiting. The spinal fluid analysis revealed invasion of lymphocytic inflammatory cells and high
adenosine deaminase activity; the patient was thus diagnosed with
tuberculous meningitis. His condition gradually improved after the changing of the
anti-tuberculosis drugs. Thus, to summarize, the
tuberculous meningitis had worsened paradoxically despite his systemic improvement, although it was successfully treated by the addition of LVFX and SM. We must keep in mind that a potential cause of
fever during anti-
tuberculosis therapy may be INH-resistant
tuberculous meningitis.