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<p>Central nervous system (CNS) involvement is one of the most devastating clinical manifestations of tuberculosis (TB) noted in 5 to 10% of patients with extra pulmonary TB and accounts for approximately 1% of all patients with TB. Clinical deterioration during treatment with anti-tuberculosis drugs (ATD) is not uncommon in immunocompetent persons. Possibilities include multi-drug resistant tuberculosis (MDR-TB), a paradoxical response or some other non-tubercularcauses of fever. Corticosteroids are considered tohave a beneficial effect in the management of paradoxical reactions. Immuno-modulatory drugs, including tumour necrosis factor-α antagonists, thalidomide and interferon-γ have beenused in isolated cases with more severe forms of paradoxical reactions.We report here a case of a 13 year old girl who while being treated for tubercular meningitis, developed high grade fever with lymphadenopathy. Her lymph node biopsy showed caseous necrosis with presence of AFB suggestive of a paradoxical reaction.</p>