Recurrent Paradoxical Reactions in Cervical Tuberculous Lymphadenitis During and after Antitubercular Therapy in an Immunocompetent Patient

Paradoxical reaction (PR) in lymph node tuberculosis (LNTB) is characterized by the worsening of existing lesions or the appearance of new lesions after an initial favourable response to antitubercular therapy (ATT). Although frequently reported in HIV-infected individuals, it can also occur in immunocompetent patients and may be mistaken for treatment failure or disease relapse. We report a 25-year-old immunocompetent woman with microbiologically confirmed cervical LNTB who developed recurrent lymph node enlargement during ATT and again after completing treatment. The diagnosis was established by excisional lymph node biopsy demonstrating necrotizing granulomatous inflammation, acid-fast bacilli on Ziehl–Neelsen staining, and detection of Mycobacterium tuberculosis by GeneXpert without rifampicin resistance. Despite initial clinical improvement, she experienced multiple episodes of cervical lymphadenopathy. During these episodes, smear microscopy and GeneXpert remained positive, whereas mycobacterial cultures were repeatedly negative. Following careful microbiological reassessment, the enlargements were managed conservatively without extending or modifying ATT. The lesions resolved spontaneously, and no constitutional symptoms or evidence of viable bacilli were identified. This case highlights the diagnostic challenge of distinguishing paradoxical reactions from relapse or treatment failure in LNTB. Repeated negative cultures, absence of clinical deterioration, and spontaneous resolution without therapeutic escalation supported the diagnosis of PR. Recognition of this phenomenon is essential to avoid unnecessary investigations and prolonged treatment.