An HIV-positive patient with CD4 count of 65 cells/µL is started on ART. Two weeks later he develops worsening fever, lymphadenopathy, and new pulmonary infiltrates. CD4 has risen to 120 cells/µL. The MOST likely explanation is:
- A ART treatment failure
- B Immune reconstitution inflammatory syndrome (IRIS) ✓
- C New opportunistic infection despite ART
- D Drug hypersensitivity reaction to ART
Explanation
Immune reconstitution inflammatory syndrome (IRIS) occurs in the first weeks after ART initiation when the recovering immune system mounts an exaggerated inflammatory response to previously subclinical or treated opportunistic infections. Paradoxical IRIS (worsening of a known OI after treatment) and unmasking IRIS (revealing previously unknown subclinical infection) are the two forms. Features include new or worsening clinical manifestations with a rising CD4 count and suppressing viral load. Risk factors include very low baseline CD4 (<50), early ART initiation, and high antigen burden. Treatment depends on severity; NSAIDs or corticosteroids for severe cases.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.