Question | Discussion | References

Updated November 22, 2011

Diagnosis and Management of Tuberculosis Immune Reconstitution Inflammatory Syndrome (TB-IRIS)

Authors: G. Manoharan, MD Christopher Behrens, MD

A 34-year-old HIV-infected man from southern India is diagnosed with pulmonary tuberculosis (TB) based on symptoms of hemoptysis and weight loss, characteristic findings on chest radiograph (Figure 1), and a sputum smear positive for acid-fast bacilli (AFB). His absolute CD4 count at the time of diagnosis is 60 cells/mm3, and he has never taken antiretroviral therapy. He is started on anti-TB therapy consisting of isoniazid, rifampin, ethambutol, and pyrazinamide. Two months later, he has a normal chest radiograph (Figure 2) and his sputum is negative on AFB staining. At that time, he begins antiretroviral therapy with a regimen of zidovudine, lamivudine, and efavirenz. He returns to clinic 2 months later complaining of chest pain and fever; his vital signs are normal. A chest radiograph performed at that time shows a right-sided pleural effusion (Figure 3) with right upper lobe infiltrates (Figure 4). His absolute CD4 count is now 166 cells/mm3.

Which of the following would you recommend regarding the management of this patient?

A Optimal management at this point consists of administering corticosteroids, continuing TB therapy, and withholding antiretroviral therapy until his clinical symptoms improve and his chest radiograph has cleared.
B The patient has likely developed multidrug-resistant TB; his TB regimen should empirically be changed and antiretroviral therapy should be continued.
C Given that his CD4 count is still less than 200 cells/mm3, a new opportunistic infection best explains the worsening clinical course and he should undergo an intensive evaluation for a new opportunistic infection.
D Optimal management at this point consists of continuing antiretroviral medications and TB therapy without change, obtaining sputum cultures to rule out drug-resistant TB, and administering corticosteroids if his clinical condition deteriorates further.

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    Figure 1. Chest Radiograph of Patient at Initial Presentation

    The chest radiograph shows a right-sided pleural effusion in a patient newly diagnosed with tuberculosis.
    Source: Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India


    Figure 1
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    Figure 2. Chest Radiograph after 2 Months of Anti-TB Therapy

    Note the resolution of the pleural effusion and absence of pulmonary infiltrates.
    Source: Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India


    Figure 2
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    Figure 3. Chest Radiograph of Patient after 2 Months of Antiretroviral Therapy

    The pleural effusion has recurred following 2 months of antiretroviral therapy; the patient was still taking anti-TB therapy.
    Source: Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India


    Figure 3
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    Figure 4. Chest Radiograph Detail of Region in Right Upper Lobe after 2 Months of Antiretroviral Therapy

    This image shows a magnified view of a region in the right upper lobe and subtle pulmonary infiltrates are evident. This chest radiograph was taken 2 months after starting antiretroviral therapy and the patient was still taking anti-TB therapy.
    Source: Government Hospital of Thoracic Medicine, Tambaram Sanatorium, Chennai, India


    Figure 4