A 44-year-old HIV-positive woman (CD4 count 200 cells/μL) is started on ART. Three weeks later she develops high fever, cervical lymphadenopathy, and mediastinal lymph nodes on CXR. Sputum AFB is positive. She was diagnosed with TB 1 month ago and started on ATT. What is the most likely diagnosis and the recommended approach?

• A ATT failure; switch to second-line anti-TB regimen
• B Immune Restoration Disease — stop ART temporarily
• C Drug-resistant TB; send sputum for DST and pause ART
• D Immune Reconstitution Inflammatory Syndrome (IRIS); continue ATT and ART, add corticosteroids if severe ✓

Explanation

IRIS (immune reconstitution inflammatory syndrome) — specifically paradoxical TB-IRIS — occurs when ART is started shortly after TB treatment initiation, leading to exaggerated inflammatory response as the recovering immune system reacts to residual mycobacterial antigens. It typically occurs 2–8 weeks after ART initiation. Management is to continue both ART and ATT; systemic corticosteroids (prednisolone 1.5 mg/kg/day) are added for severe or life-threatening IRIS. Stopping ART is not recommended. ATT is not failing — the mycobacterial burden was pre-existing.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.