An Unexpected Twist: Paradoxical Pleural Effusion during Pott’s Spine Management

Abstract

Paradoxical pleural effusion refers to the appearance or worsening of a pleural effusion during anti-tubercular therapy (ATT), despite initial clinical or radiological improvement. It can manifest as a new or enlarging effusion, often contralateral to the primary disease focus. Paradoxical reactions are well-recognized complications of ATT, most commonly described in lymph node and central nervous system tuberculosis. Paradoxical pleural effusion, particularly in extrapulmonary TB such as spinal disease, is rare and under-reported. We describe the case of a 34-year-old female with thoracic spinal tuberculosis who developed a right-sided pleural effusion three weeks after initiation of ATT, despite a normal baseline chest X-ray. The case emphasizes the importance of recognizing this immune-mediated phenomenon to avoid unnecessary changes in therapy or invasive diagnostic procedures.