Pleural effusion secondary to tuberculosis is second most common manifestation of extrapulmonary tuberculosis. Tuberculous pleural effusion is more frequently documented in India due to high TB burden setting and usually cured with universally available ATT as per NTEP program. Very few cases showed inadequate treatment response and these cases require addition of steroids to relive symptoms. Addition of steroids in management of TB pleural effusion is not routinely indicated and not recommended by NTEP as well. Clinical deterioration during antituberculosis therapy in patients whose cases have initially improved is known as a “paradoxical reaction.” In this case report, a 54-year teacher male presented with constitutional symptoms with right upper lobe nodular opacity with infiltrates treated empirically for community acquired pneumonia and progressed to left massive pleural effusion with respiratory distress diagnosed as case of Tuberculous pleural effusion by reporting raised ADA level and CBNAAT test results with MTB genome and negative Rifampicin (rpo-b) mutation. He is treated according to NTEP guided ATT schedule as per weight band in line with drug sensitive tuberculosis. He has shown good clinical and radiological response in first six weeks to ATT and later showed clinical and radiological worsening. We further reassessed and confirmed drug sensitive tuberculosis and continued same regimen. We have further evaluated for possibility of immune dysregulation in present case by doing TH1 and TH2 markers and observed TH1-TH2 dysregulation and also significantly raised IgE level. We have started oral steroids which were contoured till six weeks in tapering order along with ATT and documented significant improvement in clinical and radiological response. We have observed near complete resolution of pleural effusion after seven months and documented clinical and radiological cure after eight months of ATT. Paradoxical reaction is not uncommon, but needs prompt workup to rule out underlying drug resistant tuberculosis. Short course of steroids will give symptomatic relief in drug sensitive tuberculosis along with ATT. We recommend to rule out immune dysregulation in cases with drug sensitive recurrent pleural effusion in spite of acceptable adherence with good quality drugs for adequate duration which have showed excellent initial response to ATT.

Lemmel’s syndrome is a rare and misdiagnosed cause of obstructive jaundice, It corresponds to cholestatic disease secondary to compression of the main bile duct by a periampullary duodenal diverticulum with secondary dilation of the extra- and intra-hepatic bile ducts. Approximately 5% of duodenal diverticles can cause symptoms and 1% have complications, with colangitis being the most common. Lemmel syndrome is a type of intermittent obstructive jaundice without the presence of coledocolithiasis. Late diagnosis of this entity is common and may lead to unnecessary further investigations and therapeutic delay. There are no cases reports published associated with secondary sclerosing colangitis.