An Uncommon Cause of Elevated Liver Transaminases: Immune Reconstitution Inflammatory Syndrome from Unmasking of Occult Mycobacterium Avium Complex Infection in an HIV Infected Patient

Abstract

Abnormal liver chemistry from the development of immune reconstitution inflammatory syndrome (IRIS) may reflect an unmasking of subclinical disease. We present the case of a 37-year-old female with a mixed pattern of liver injury from disseminated mycobacterium avium complex infection after starting antiretroviral therapy (ART). Presenting symptoms were fever, confusion, dysphagia, and abdominal discomfort for one week. Exam revealed a fever of 103.2°F, hypotension, encephalopathy, and abdominal tenderness. Lab work was significant for acute normocytic anemia, leukopenia, absolute CD4 count 28 cells/cmm, HIV viral load 276 viral copies/ml (vc/ml), ALT 267 U/L, AST 484 U/L, alkaline phosphatase 342 U/L, and normal total bilirubin. Imaging revealed hepatomegaly with steatosis and mesenteric and retroperitoneal lymphadenopathy. Percutaneous liver biopsy demonstrated noncaseating granulomas with AFB-positive organisms, with AFB blood cultures growing Mycobacterium avium complex (MAC), consistent with disseminated MAC infection. Clinicians must have a high index of suspicion for IRIS when determining the etiology of elevated liver transaminases in patients with HIV.