A 32-year-old man with HIV (CD4 count 62 cells/µL, viral load 180,000 copies/mL) is started on antiretroviral therapy (ART). Three weeks later he develops fever, cervical lymphadenopathy, and worsening of previously stable pulmonary infiltrates attributed to old TB. What is the diagnosis, and what is the appropriate management?

• A ART failure — switch antiretroviral regimen immediately
• B New opportunistic infection — broaden antimicrobial coverage
• C Drug-induced immune reaction — stop ART and restart after the episode resolves
• D Immune reconstitution inflammatory syndrome (IRIS) — continue ART and add corticosteroids if severe ✓

Explanation

Immune reconstitution inflammatory syndrome (IRIS) — specifically paradoxical TB-IRIS — occurs in 8–43% of HIV-TB co-infected patients starting ART, typically within 4–8 weeks. It is characterised by paradoxical worsening of a previously treated infection as the recovering immune system mounts an exaggerated inflammatory response against residual mycobacterial antigens. Risk factors include very low CD4 (< 50 cells/µL), high viral load, and short interval between starting TB treatment and ART. Management: continue ART (do not stop), continue anti-TB therapy, and add corticosteroids (prednisolone 1.5 mg/kg/day tapered over 4 weeks) for severe IRIS — as shown in the IMPAACT REMEMBER trial. Stopping ART allows immune reconstitution to reverse and is not recommended except in life-threatening IRIS.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.