Multifocal tuberculosis-associated immune reconstitution inflammatory syndrome: case report of a complicated scenario

Background:

Tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) represents a significant challenge in managing HIV-TB patients starting antiretroviral therapy (ART). It occurs in two scenarios: unmasking (previously undiagnosed TB) or paradoxical (worsening of treated TB). Pathogenesis involves the failure to eliminate M. tuberculosis during severe immunosuppression, followed by abrupt immune activation upon ART.

Abstract:

Case Presentation: We present a rare and complex case of a 51-year-old woman living with HIV (CD4 count: 51 $cells/\mu L$) who experienced a series of sequential TB-IRIS events at multiple sites. After 32 days of ART, she developed unmasking pulmonary TB. This was followed 48 days later by a hepatic portal event involving jaundice and periportal nodes. After re-starting ART, she suffered focal convulsions due to a brain tuberculoma (CNS-IRIS). Finally, months after completing anti-TB treatment, she developed an intramuscular abscess in the left iliac fossa.

Conclusion: This multifocal and successive presentation of TB-IRIS highlights the extreme clinical complexity in diagnosis and management for highly immunosuppressed patients. INTERRUPTING art and organ-specific drug penetration are critical factors to consider in such scenarios.

Keywords: Immune reconstitution inflammatory syndrome, IRIS, Tuberculosis, HIV.

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• Data de Publicação: 17/06/2019
• Autores: Gopalan Narendran1† , Deivide Oliveira-de-Souza2,3,4† , Caian L. Vinhaes2,3,4† , Kevan Akrami2,5, Kiyoshi F. Fukutani2,3,4, Kesavamurthy Banu6 , Padmapriyadarsini Chandrasekaran1 , Narayanan Ravichandran7 , Irini Sereti8 , Soumya Swaminathan1 and Bruno B. Andrade2,3,4,9,10,11,12*