In the past decades, tumor necrosis factor alpha (TNF-a) antagonist has been a milestone in the treatment of many chronic inflammatory diseases. TNF antagonist can increase patients´ susceptibility to many different kinds of infections especially those requiring granuloma formations despite regular performance of Screening for latent tuberculosis infection (LTBI). We report 2 cases of patients who developed tuberculosis under treatment with adalimumab, which was discontinued after the diagnosis of tuberculosis. During the tuberculosis therapy they unexpectedly developed a prolonged paradoxical reaction. In both cases we were only able to manage the progress of the paradoxical reaction through high steroid doses. Patients undergoing therapy with TNF- alphablocker are prone to develop tuberculosis infection, which could in turn lead to severe prolonged paradoxical reaction during anti-tuberculous treatment. An increased steroid dose may be required and is sometimes necessary
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 Lawn SD, Wilkinson RJ, Lipman MCI, Wood R. Immune reconstitution and “unmasking” of tuberculosis during antiretroviral therapy. Am. J. Respir. Crit. Care Med. 2008 Apr 1;177(7):680-685
 Cheng VCC, Ho PL, Lee RA, Chan KS, Chan KK, Woo PCY, et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur. J. Clin. Microbiol. Infect. Dis. 2002 Nov;21(11):803-809
 Melboucy-Belkhir S, Flexor G, Stirnemann J, Morin A-S, Boukari L, Polliand C, et al. Prolonged paradoxical response to anti-tuberculous treatment after infliximab. Int. J. Infect. Dis. 2010 Sep;14 Suppl 3:e333-334
 Yoon YK, Kim JY, Sohn JW, Kim MJ, Koo JS, Choi JH, et al. Paradoxical response during antituberculous therapy in a patient discontinuing infliximab: a case report. J Med Case Reports. 2009;3:6673
 Garcia Vidal C, Rodríguez Fernández S, Martínez Lacasa J, Salavert M, Vidal R, Rodríguez Carballeira M, et al. Paradoxical response to antituberculous therapy in infliximab-treated patients with disseminated tuberculosis. Clin. Infect. Dis. 2005 Mar 1;40(5):756-759
 Hess S, Hospach T, Nossal R, et al. Life- threatening disseminated tuberculosis as a complication of TNF- a blockade in an adolescent. Eur J Pediatr. Volume 170, Number 10, 1337-1342
 Wallis RS, Broder MS, Wong JY et al (2004) Granulomatous infectious diseases associated with TNF antagonists. Clin Infect Dis 38: 1261-1265
 Wallis RS, Broder MS, Wong JY et al (2004) Granulomatous infections due to tumor necrosis factor blockade: correction. Clin Infect Dis 39: 1254-1256
 Meintjes G, Wilkinson RJ, Morroni C et al (2010) Randomized placebo- controlled trial of prednisone for paradoxical tuberculosis- associated immune reconstitution inflammatory syndrome. AIDS 24: 2381-2390
 Wallis RS, Van Vuuren C, Potgieter S. Adalimumab treatment of life- threatening tuberculosis. Clin. Infect. Dis. 2009 May 15; 48 (10): 1429-1432
 Blackmore TK, Manning L, Taylor WJ, et al. Therapeutic use of infliximab in tuberculosis to control severe paradoxical reaction of the brain and lymph nodes. Clin. Infect. Dis. 2008 Nov 15; 47 (10): e 83-85
 Jurisic V, Stojacic- Djenic S, Colovic N and Konjevic G. The role of cytokine in regulation of the natural killer cell activity. Srp Arh Celok Lek. 2008 Jul-Aug;136(7-8):423-429
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