Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) was first described almost two decades ago. We undertook this systematic review and meta-analysis to collate findings across studies that have reported the incidence, clinical features, management and outcomes of paradoxical TB-IRIS. Forty studies that cumulatively reported 1048 paradoxical TB-IRIS cases were included. The pooled estimated incidence among patients with HIV-associated TB initiating antiretroviral therapy was 18% (95% CI: 16–21%). Frequent features were pulmonary and lymph node involvement. Hospitalization occurred in 25% (95% CI: 19–30%). In studies that reported treatment, corticosteroids were prescribed more frequently (38%; 95% CI: 27–48%) than nonsteroidal anti-inflammatory drugs (28%; 95% CI: 2–53%). Case fatality was 7% (95% CI: 4–11%), but death attributed to TB-IRIS occurred in 2% of cases (95% CI: 1–3%).